Basic Information
| Provider Information | |||||||||
| NPI: | 1518952407 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAVAZZO | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | ANGELO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.P.M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3733 PARK EAST DR | ||||||||
| Address2: | SUITE 240 | ||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441224338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162451290 | ||||||||
| FaxNumber: | 8665714884 | ||||||||
| Practice Location | |||||||||
| Address1: | 8984 DARROW RD | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | TWINSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440872186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162451290 | ||||||||
| FaxNumber: | 8665714884 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2005 | ||||||||
| LastUpdateDate: | 09/07/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 36-003320 | OH | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2406524 | 05 | OH | MEDICAID | 5315240001 | 01 | OH | DMERC | OTHER |