Provider Demographics
NPI:1265726749
Name:FAVA, JOHN M (PT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:FAVA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:463 WORCESTER RD
Mailing Address - Street 2:
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01701-5356
Mailing Address - Country:US
Mailing Address - Phone:508-872-5133
Mailing Address - Fax:508-628-9788
Practice Address - Street 1:8 POST OFFICE SQ
Practice Address - Street 2:
Practice Address - City:ACTON
Practice Address - State:MA
Practice Address - Zip Code:01720-3948
Practice Address - Country:US
Practice Address - Phone:978-881-0090
Practice Address - Fax:978-881-0091
Is Sole Proprietor?:No
Enumeration Date:2011-06-02
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11466225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist