Provider Demographics
NPI:1982130985
Name:FAVREAU DERMATOLOGY LLC
Entity Type:Organization
Organization Name:FAVREAU DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:MR
Authorized Official - First Name:MO
Authorized Official - Middle Name:
Authorized Official - Last Name:TOLEDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-457-4201
Mailing Address - Street 1:201 SE 14TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-1827
Mailing Address - Country:US
Mailing Address - Phone:954-457-4201
Mailing Address - Fax:
Practice Address - Street 1:201 SE 14TH ST
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-1827
Practice Address - Country:US
Practice Address - Phone:954-457-4201
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9004207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty