Provider Demographics
NPI:1003044256
Name:FAVREAU, STEPHANIE P (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:P
Last Name:FAVREAU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:P
Other - Last Name:TECUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:400 BALD HILL RD
Mailing Address - Street 2:SUITE 520
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-1617
Mailing Address - Country:US
Mailing Address - Phone:401-793-8520
Mailing Address - Fax:401-793-8527
Practice Address - Street 1:400 BALD HILL RD
Practice Address - Street 2:SUITE 520
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-1617
Practice Address - Country:US
Practice Address - Phone:401-793-8520
Practice Address - Fax:401-793-8527
Is Sole Proprietor?:No
Enumeration Date:2009-06-26
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD14368208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIU400161903Medicare PIN