Healthcare Provider Details

I. General information

NPI: 1548570591
Provider Name (Legal Business Name): THOMAS W FANTAUZZO C.PED
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2010
Last Update Date: 09/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 CLINTON AVE S FEET FIRST INC.
ROCHESTER NY
14618-5621
US

IV. Provider business mailing address

46 CAPRI DR THOMAS FANTAUZZO
ROCHESTER NY
14624-1357
US

V. Phone/Fax

Practice location:
  • Phone: 585-442-4990
  • Fax:
Mailing address:
  • Phone: 585-247-7809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224L00000X
TaxonomyPedorthist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: