MEDICARE: LAURENCE DEKANTER FAVROT 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	207RC0000X	Cardiovascular Disease Physician	C37396	CA

General Provider Information

NPI Number	:	1609906841
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURENCE DEKANTER FAVROT MD

Provider Business Mailing Address
First Line	:	3526 7TH AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-5009
Country	:	US
Telephone Number	:	858-499-3080
Fax Number	:	858-499-4441

Provider Business Practice Location Address
First Line	:	3526 7TH AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-5009
Country	:	US
Telephone Number	:	858-499-3080
Fax Number	:	858-499-4441

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

Provider Enumeration Date	:	03/06/2007
Last Update Date	:	07/08/2007

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