Provider Demographics
NPI:1205891439
Name:FAYLONA, RENATO T (MD)
Entity type:Individual
Prefix:
First Name:RENATO
Middle Name:T
Last Name:FAYLONA
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:PO BOX 840
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN DELLS
Mailing Address - State:WI
Mailing Address - Zip Code:53965-0840
Mailing Address - Country:US
Mailing Address - Phone:608-253-1171
Mailing Address - Fax:608-253-8012
Practice Address - Street 1:1310 BROADWAY RD
Practice Address - Street 2:
Practice Address - City:WISCONSIN DELLS
Practice Address - State:WI
Practice Address - Zip Code:53965-1358
Practice Address - Country:US
Practice Address - Phone:608-253-1171
Practice Address - Fax:608-253-8012
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19822-020208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1006070OtherPHYSICIANS PLUS
WI3768OtherDEAN HEALTH INSURANCE
WI30997800Medicaid
WI30997800Medicaid
WI000913215Medicare PIN
WI003357155Medicare PIN
WI020050896Medicare PIN