Provider Demographics
NPI:1275826802
Name:FABREGA-FOSTER, KELLY (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:FABREGA-FOSTER
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 1:2700 UNIVERSITY SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-5513
Mailing Address - Country:US
Mailing Address - Phone:813-253-2721
Mailing Address - Fax:813-977-3720
Practice Address - Street 1:2700 UNIVERSITY SQUARE DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-5513
Practice Address - Country:US
Practice Address - Phone:813-253-2721
Practice Address - Fax:813-977-3720
Is Sole Proprietor?:No
Enumeration Date:2011-05-16
Last Update Date:2017-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1325582085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020977700Medicaid