Healthcare Provider Details

I. General information

NPI: 1720781677
Provider Name (Legal Business Name): ANDREW FAVRE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2023
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1270 PRINCE AVE STE 201
ATHENS GA
30606-2789
US

IV. Provider business mailing address

1199 PRINCE AVE # 70
ATHENS GA
30606-2797
US

V. Phone/Fax

Practice location:
  • Phone: 706-475-7055
  • Fax:
Mailing address:
  • Phone: 706-475-7055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number110159
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: