Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RH0003X | Hematology & Oncology | 2003-00782 | NC |
NPI | 1053365320 |
---|---|
Provider Name | Dr. Justin P Favaro |
First Address | Charlotte, NC 28204-4319 |
Second Address | Charlotte, NC 28204-4319 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/05/2006 |
Last Update Date | 13/03/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
BF8249838 | DEA (01) |