MEDICARE: DR. KELLI RAYNELL FAVATA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	30177	SC
2	207R00000X	Internal Medicine Physician	45344	AZ
3	246XC2903X	Vascular Specialist/Technologist Cardiovascular	45344	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184822348
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLI RAYNELL FAVATA M.D.

Provider Business Mailing Address
First Line	:	3820 NORTHDALE BLVD STE 201
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33624-1893
Country	:	US
Telephone Number	:	800-911-6117
Fax Number	:

Provider Business Practice Location Address
First Line	:	3530 S VAL VISTA DR STE B210
Second Line	:
City	:	GILBERT
State	:	AZ
Zip	:	85297-7318
Country	:	US
Telephone Number	:	800-991-6117
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/10/2007
Last Update Date	:	02/15/2025

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