Provider Demographics
NPI:1376745612
Name:LAFAVE, KELLY E (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:E
Last Name:LAFAVE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ALLISON
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:483 N SEMORAN BLVD STE 107
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-3800
Mailing Address - Country:US
Mailing Address - Phone:407-539-0722
Mailing Address - Fax:407-539-0723
Practice Address - Street 1:483 N SEMORAN BLVD STE 107
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-3800
Practice Address - Country:US
Practice Address - Phone:407-539-0722
Practice Address - Fax:407-539-0723
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1069042085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDJ631ZOtherMEDICARE ID
FL0022468Medicaid