Provider Demographics
NPI:1871772038
Name:JOSEPH A FAVAZZO DPM LL
Entity type:Organization
Organization Name:JOSEPH A FAVAZZO DPM LL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:ANGELO
Authorized Official - Last Name:FAVAZZO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:330-963-4880
Mailing Address - Street 1:8984 DARROW ROAD
Mailing Address - Street 2:STE 2
Mailing Address - City:TWINSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:44087
Mailing Address - Country:US
Mailing Address - Phone:330-963-4880
Mailing Address - Fax:440-461-3279
Practice Address - Street 1:8984 DARROW ROAD
Practice Address - Street 2:STE 2
Practice Address - City:TWINSBURG
Practice Address - State:OH
Practice Address - Zip Code:44087
Practice Address - Country:US
Practice Address - Phone:330-963-4880
Practice Address - Fax:440-461-3279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36-003320213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2406524Medicaid
OHJ09334871OtherMEDICARE GROUP NUMBER
OH5315240001OtherDMERC
OHP00044963OtherMEDICARE RAILROAD