Basic Information
| Provider Information | |||||||||
| NPI: | 1013912625 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAVILLI | ||||||||
| FirstName: | LUIS | ||||||||
| MiddleName: | CLYDE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 NORTH LANIER AVE | ||||||||
| Address2: | |||||||||
| City: | FORT MEADE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338412918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632857171 | ||||||||
| FaxNumber: | 8632856701 | ||||||||
| Practice Location | |||||||||
| Address1: | 3650 INNOVATION DR | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338124105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607091968 | ||||||||
| FaxNumber: | 8637012151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2005 | ||||||||
| LastUpdateDate: | 04/06/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME56610 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 374563500 | 05 | FL | MEDICAID |