Healthcare Provider Details

I. General information

NPI: 1427069681
Provider Name (Legal Business Name): PAUL FANTAUZZO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2031 BELMONT AVE
YOUNGSTOWN OH
44505-2401
US

IV. Provider business mailing address

2031 BELMONT AVE
YOUNGSTOWN OH
44505-2401
US

V. Phone/Fax

Practice location:
  • Phone: 330-740-9200
  • Fax: 330-740-9251
Mailing address:
  • Phone: 330-740-9200
  • Fax: 330-740-9251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34-00-6409F
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: