Healthcare Provider Details

I. General information

NPI: 1396852364
Provider Name (Legal Business Name): THOMAS R FANN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 11/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 STATE RD 436 SUITE 1400
CASSELBERRY FL
32707
US

IV. Provider business mailing address

1120 STATE RD 436 SUITE 1400
CASSELBERRY FL
32707
US

V. Phone/Fax

Practice location:
  • Phone: 407-671-8010
  • Fax: 407-671-4155
Mailing address:
  • Phone: 407-671-8010
  • Fax: 407-671-4155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO0001035
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: