Provider Demographics
NPI:1902656838
Name:FAVO, CLINNT LUNA (DO)
Entity Type:Individual
Prefix:DR
First Name:CLINNT
Middle Name:LUNA
Last Name:FAVO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20000 N 57TH AVE RM D102
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-6837
Mailing Address - Country:US
Mailing Address - Phone:619-823-0338
Mailing Address - Fax:
Practice Address - Street 1:500 J CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-1929
Practice Address - Country:US
Practice Address - Phone:757-612-7277
Practice Address - Fax:757-594-3184
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program