Basic Information
| Provider Information | |||||||||
| NPI: | 1336321835 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LUIS C FAVILLI MD LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAVILLI FAMILY PRACTICE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6675 WESTWOOD BLVD | ||||||||
| Address2: | STE 475 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328218061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078450330 | ||||||||
| FaxNumber: | 8889721752 | ||||||||
| Practice Location | |||||||||
| Address1: | 3650 INNOVATION DR | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338124105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636466295 | ||||||||
| FaxNumber: | 8637012151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2007 | ||||||||
| LastUpdateDate: | 04/27/2017 | ||||||||
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| AuthorizedOfficialLastName: | FAVILLI | ||||||||
| AuthorizedOfficialFirstName: | LUIS | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | FAMILY PRACTICE | ||||||||
| AuthorizedOfficialTelephone: | 8632857171 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME0056610 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | E49325 | 05 | FL | MEDICAID |