Provider Demographics
NPI:1013912625
Name:FAVILLI, LUIS CLYDE (MD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:CLYDE
Last Name:FAVILLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6675 WESTWOOD BLVD STE 475
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32821-6027
Mailing Address - Country:US
Mailing Address - Phone:407-845-0330
Mailing Address - Fax:888-972-1752
Practice Address - Street 1:3650 INNOVATION DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33812-4105
Practice Address - Country:US
Practice Address - Phone:860-709-1968
Practice Address - Fax:863-701-2151
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME56610207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL374563500Medicaid
FL374563500Medicaid
FL10246ZMedicare ID - Type Unspecified