Provider Demographics
NPI:1396794913
Name:DORVILLE, FABIO LOPES (MD)
Entity type:Individual
Prefix:DR
First Name:FABIO
Middle Name:LOPES
Last Name:DORVILLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN HILL
Mailing Address - State:PA
Mailing Address - Zip Code:18015-4117
Mailing Address - Country:US
Mailing Address - Phone:610-868-2710
Mailing Address - Fax:610-868-6130
Practice Address - Street 1:1130 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:FOUNTAIN HILL
Practice Address - State:PA
Practice Address - Zip Code:18015-4117
Practice Address - Country:US
Practice Address - Phone:610-868-2710
Practice Address - Fax:610-868-6130
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD037390-L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA109772OtherBLUE SHIELD
PA124535QJMMedicare ID - Type Unspecified
B37339Medicare UPIN