Healthcare Provider Details

I. General information

NPI: 1922192061
Provider Name (Legal Business Name): DRS. FAVEDE & ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 12/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 THIRD STREET
BRIDGEPORT OH
43912-1605
US

IV. Provider business mailing address

100 THIRD ST
BRIDGEPORT OH
43912-1605
US

V. Phone/Fax

Practice location:
  • Phone: 740-635-0814
  • Fax: 740-635-2521
Mailing address:
  • Phone: 740-635-0814
  • Fax: 740-635-2521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. LEON MICHAEL FAVEDE
Title or Position: PARTNER
Credential: O.D.
Phone: 740-635-0814