MEDICARE: DR. LUIS CLYDE FAVILLI MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	ME56610	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013912625
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LUIS CLYDE FAVILLI MD

Provider Business Mailing Address
First Line	:	6675 WESTWOOD BLVD STE 475
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32821-6027
Country	:	US
Telephone Number	:	407-845-0330
Fax Number	:	888-972-1752

Provider Business Practice Location Address
First Line	:	3650 INNOVATION DR
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33812-4105
Country	:	US
Telephone Number	:	860-709-1968
Fax Number	:	863-701-2151

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/20/2005
Last Update Date	:	05/30/2023

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