Healthcare Provider Details

I. General information

NPI: 1396741260
Provider Name (Legal Business Name): GARY ALDO FANTINI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 08/02/2024
Certification Date: 08/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 E 70TH ST
NEW YORK NY
10021-4823
US

IV. Provider business mailing address

535 E 70TH ST
NEW YORK NY
10021-4823
US

V. Phone/Fax

Practice location:
  • Phone: 212-606-1427
  • Fax: 212-774-7175
Mailing address:
  • Phone: 212-606-1427
  • Fax: 212-774-7175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number161192
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: