Basic Information
| Provider Information | |||||||||
| NPI: | 1083380455 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAVELA | ||||||||
| FirstName: | ALEXANDER | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4400 N LINCOLN BLVD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731055108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054247711 | ||||||||
| FaxNumber: | 4054250437 | ||||||||
| Practice Location | |||||||||
| Address1: | 4400 N LINCOLN BLVD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731055108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054247711 | ||||||||
| FaxNumber: | 4054250437 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2021 | ||||||||
| LastUpdateDate: | 08/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | Y |
No ID Information.