Healthcare Provider Details

I. General information

NPI: 1841263225
Provider Name (Legal Business Name): JOHN ANDREW FANTL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 05/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 UNION SQ E FRNT 2E
NEW YORK NY
10003-3314
US

IV. Provider business mailing address

PO BOX 95000-2428
PHILADELPHIA PA
19195-2428
US

V. Phone/Fax

Practice location:
  • Phone: 212-844-8521
  • Fax:
Mailing address:
  • Phone: 212-844-8521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number1988811
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: