Provider Demographics
NPI:1215572417
Name:FAVOT, ANTHONY ALONZO
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:ALONZO
Last Name:FAVOT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 SIDON AVE.
Mailing Address - Street 2:
Mailing Address - City:LA HABRA
Mailing Address - State:CA
Mailing Address - Zip Code:90631
Mailing Address - Country:US
Mailing Address - Phone:734-842-2232
Mailing Address - Fax:
Practice Address - Street 1:2500 SIDON AVE.
Practice Address - Street 2:
Practice Address - City:LA HABRA
Practice Address - State:CA
Practice Address - Zip Code:90631
Practice Address - Country:US
Practice Address - Phone:734-842-2232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-12
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty