Provider Demographics
NPI:1801831201
Name:FAVRE, KELLY A (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:FAVRE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1951 N WILMOT RD
Mailing Address - Street 2:BUILDING 2
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-8000
Mailing Address - Country:US
Mailing Address - Phone:520-795-5845
Mailing Address - Fax:520-795-8620
Practice Address - Street 1:1951 N WILMOT RD
Practice Address - Street 2:BUILDING 2
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-8000
Practice Address - Country:US
Practice Address - Phone:520-795-5845
Practice Address - Fax:520-795-8620
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ29627208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZH58063Medicare UPIN
AZ107584Medicare ID - Type Unspecified
AZAZ0153340OtherBCBS
AZH58063Medicare UPIN
AZ2Z2615OtherHEALTH NET
AZ691924-02OtherAHCCCS