Basic Information
| Provider Information | |||||||||
| NPI: | 1235194861 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WEENA CHUA FAVIS MD PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LAKE PRIME CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 33041 PROFESSIONAL DR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | LEESBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347883760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523651224 | ||||||||
| FaxNumber: | 3523650786 | ||||||||
| Practice Location | |||||||||
| Address1: | 33041 PROFESSIONAL DR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | LEESBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347883760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523651224 | ||||||||
| FaxNumber: | 3523650786 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| LastUpdateDate: | 03/15/2016 | ||||||||
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| AuthorizedOfficialLastName: | FAVIS | ||||||||
| AuthorizedOfficialFirstName: | WEENA | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3523651224 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 203BI03004 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.