Provider Demographics
NPI:1144273343
Name:FAVATA JR, JOHN J (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:J
Last Name:FAVATA JR
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 1:12479 TELECOM DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33637-0913
Mailing Address - Country:US
Mailing Address - Phone:813-972-4199
Mailing Address - Fax:813-972-5753
Practice Address - Street 1:3100 E FLETCHER AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-4613
Practice Address - Country:US
Practice Address - Phone:813-971-6000
Practice Address - Fax:813-615-7590
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME20637207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL29811OtherBCBS OF FLORIDA
FL29811ZMedicare PIN
FL29811OtherBCBS OF FLORIDA
FL29811XMedicare PIN
D62100Medicare UPIN