Healthcare Provider Details

I. General information

NPI: 1609219914
Provider Name (Legal Business Name): STEPHEN J FANTAUZZO C.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2013
Last Update Date: 04/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7100 BROADWAY SUITE 2E
DENVER CO
80221-2915
US

IV. Provider business mailing address

1454 STERLING HILL CT
CASTLE ROCK CO
80104-7605
US

V. Phone/Fax

Practice location:
  • Phone: 303-316-2615
  • Fax: 303-331-9019
Mailing address:
  • Phone: 303-907-9686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: