Provider Demographics
NPI:1154418697
Name:FAVIA, JULIE R (MD)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:R
Last Name:FAVIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-7401
Mailing Address - Country:US
Mailing Address - Phone:815-337-7100
Mailing Address - Fax:815-337-4793
Practice Address - Street 1:2000 LAKE AVE
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-7401
Practice Address - Country:US
Practice Address - Phone:815-337-7100
Practice Address - Fax:815-337-4793
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY55998207V00000X
TXT4359207V00000X
CODR.0067263207V00000X
IL036111396207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIFAVIAJULOtherMERCYCARE INSURANCE
WI1154418697OtherBCBSWI
IL036111396 2Medicaid
WI1154418697OtherBCBSWI
IL036111396 2Medicaid