Healthcare Provider Details

I. General information

NPI: 1629909445
Provider Name (Legal Business Name): ANTONINO FAVIA
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10501 FGCU BLVD S
FORT MYERS FL
33965-6502
US

IV. Provider business mailing address

7737 JEWEL LN APT 203
NAPLES FL
34109-0716
US

V. Phone/Fax

Practice location:
  • Phone: 914-642-4260
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: