Provider Demographics
NPI:1386765386
Name:FLORIDA PEDIATRIC PULMONOLOGY LLC
Entity type:Organization
Organization Name:FLORIDA PEDIATRIC PULMONOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:FAVERIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-466-1243
Mailing Address - Street 1:PO BOX 7518
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33911-7518
Mailing Address - Country:US
Mailing Address - Phone:239-931-7262
Mailing Address - Fax:239-931-7397
Practice Address - Street 1:15740 NEW HAMPSHIRE CT
Practice Address - Street 2:# B
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-4173
Practice Address - Country:US
Practice Address - Phone:239-466-1243
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2008-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME732202080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric PulmonologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG14058Medicare UPIN