Provider Demographics
NPI:1982600763
Name:FAVROTH, DAPHNE LOUISE (MD)
Entity type:Individual
Prefix:DR
First Name:DAPHNE
Middle Name:LOUISE
Last Name:FAVROTH
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 1:189 N PLANO RD
Mailing Address - Street 2:SUITE150
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75081-8000
Mailing Address - Country:US
Mailing Address - Phone:972-669-8400
Mailing Address - Fax:972-235-0033
Practice Address - Street 1:189 N PLANO RD
Practice Address - Street 2:SUITE150
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75081-8000
Practice Address - Country:US
Practice Address - Phone:972-669-8400
Practice Address - Fax:972-235-0033
Is Sole Proprietor?:No
Enumeration Date:2005-06-25
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA019205207R00000X, 208000000X
TXH9074208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX139297916Medicaid
TX139297917Medicaid
TX139297918Medicaid
TX139297917Medicaid
TX139297916Medicaid
TX8J2792Medicare PIN