Healthcare Provider Details

I. General information

NPI: 1386765386
Provider Name (Legal Business Name): FLORIDA PEDIATRIC PULMONOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 02/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15740 NEW HAMPSHIRE CT # B
FORT MYERS FL
33908-4173
US

IV. Provider business mailing address

PO BOX 7518
FORT MYERS FL
33911-7518
US

V. Phone/Fax

Practice location:
  • Phone: 239-466-1243
  • Fax:
Mailing address:
  • Phone: 239-931-7262
  • Fax: 239-931-7397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License NumberME73220
License Number StateFL

VIII. Authorized Official

Name: LUIS FAVERIO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 239-466-1243