Provider Demographics
NPI:1619039971
Name:FAVATA, ELISSA ANN (MD)
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:ANN
Last Name:FAVATA
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 1:1401 ROUTE 70 EAST, SUITE 14
Mailing Address - Street 2:SOUTH JERSEY MEDICAL CENTER
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034
Mailing Address - Country:US
Mailing Address - Phone:856-216-1100
Mailing Address - Fax:856-216-0484
Practice Address - Street 1:1401 ROUTE 70 EAST, SUITE 14
Practice Address - Street 2:SOUTH JERSEY MEDICAL CENTER
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034
Practice Address - Country:US
Practice Address - Phone:856-216-1100
Practice Address - Fax:856-216-0484
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04036200207R00000X, 2083P0500X
PAMD046205L207R00000X, 2083P0500X
DEC1-0004751207R00000X, 2083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC63225Medicare UPIN
NJ574041Medicare ID - Type UnspecifiedMEDICARE PROVIDER NO.