Healthcare Provider Details

I. General information

NPI: 1790874717
Provider Name (Legal Business Name): ALEX FAVELUKES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

942 SAXON BLVD STE 1A
ORANGE CITY FL
32763-8358
US

IV. Provider business mailing address

942 SAXON BLVD STE 1A
ORANGE CITY FL
32763-8358
US

V. Phone/Fax

Practice location:
  • Phone: 386-456-5293
  • Fax: 386-456-5142
Mailing address:
  • Phone: 386-456-5293
  • Fax: 386-456-5142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License NumberME95755
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: