Provider Demographics
NPI:1861481343
Name:FAVERIO, LUIS A (MD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:A
Last Name:FAVERIO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 W GORE STREET
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1101
Mailing Address - Country:US
Mailing Address - Phone:407-351-5384
Mailing Address - Fax:407-445-0321
Practice Address - Street 1:60 W GORE STREET
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1101
Practice Address - Country:US
Practice Address - Phone:407-351-5384
Practice Address - Fax:407-445-0321
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME732202080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252200400Medicaid
FLME73220OtherMEDICAL LICENSE
FL252200400Medicaid