Provider Demographics
NPI:1942294236
Name:FAVETTO, JUAN MARTIN (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:MARTIN
Last Name:FAVETTO
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 1:3480 YORKSHIRE MEDICAL PARK
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509
Mailing Address - Country:US
Mailing Address - Phone:859-263-5140
Mailing Address - Fax:859-263-5141
Practice Address - Street 1:3480 YORKSHIRE MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509
Practice Address - Country:US
Practice Address - Phone:859-263-5140
Practice Address - Fax:859-263-5141
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2017-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34804207XS0106X, 207X00000X
IN01051584A207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200152130AMedicaid
KY64348048Medicaid
0254926Medicare PIN
IN200152130AMedicaid
KYH25257Medicare UPIN
KY64348048Medicaid
KY1264415Medicare ID - Type Unspecified