Provider Demographics
NPI:1720274764
Name:MARIO FAVILLI MD PA
Entity Type:Organization
Organization Name:MARIO FAVILLI MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:NOEL
Authorized Official - Last Name:FAVILLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-481-2278
Mailing Address - Street 1:4855 W HILLSBORO BLVD
Mailing Address - Street 2:SUITE B8
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33073-4356
Mailing Address - Country:US
Mailing Address - Phone:954-481-2278
Mailing Address - Fax:954-481-1987
Practice Address - Street 1:4855 W HILLSBORO BLVD
Practice Address - Street 2:SUITE B8
Practice Address - City:COCONUT CREEK
Practice Address - State:FL
Practice Address - Zip Code:33073-4356
Practice Address - Country:US
Practice Address - Phone:954-481-2278
Practice Address - Fax:954-481-1987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0050696207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAG782Medicare PIN