Healthcare Provider Details

I. General information

NPI: 1861888018
Provider Name (Legal Business Name): DANIELA FANTO MBBS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2015
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3311 N HALSTED ST
CHICAGO IL
60657-2412
US

IV. Provider business mailing address

6255 W SUNSET BLVD FL 21
LOS ANGELES CA
90028-7422
US

V. Phone/Fax

Practice location:
  • Phone: 773-435-9994
  • Fax: 833-734-1443
Mailing address:
  • Phone: 323-860-5200
  • Fax: 323-467-7119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036154021
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: