Healthcare Provider Details

I. General information

NPI: 1396064481
Provider Name (Legal Business Name): JOHN T GANTOMASSO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2010
Last Update Date: 01/19/2024
Certification Date: 01/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 HEMLOCK ST
MACON GA
31201-2102
US

IV. Provider business mailing address

PO BOX 551420
FORT LAUDERDALE FL
33355-1420
US

V. Phone/Fax

Practice location:
  • Phone: 478-633-2147
  • Fax: 478-742-9670
Mailing address:
  • Phone: 800-243-3839
  • Fax: 855-851-4405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number336060
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number076027
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number336060
License Number StateLA
# 4
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberOS017509
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: