Healthcare Provider Details

I. General information

NPI: 1356448773
Provider Name (Legal Business Name): ROY J FERTAKOS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 09/03/2020
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 OSTRUM ST
BETHLEHEM PA
18015-1000
US

IV. Provider business mailing address

PO BOX 678398
DALLAS TX
75267-8398
US

V. Phone/Fax

Practice location:
  • Phone: 484-526-4000
  • Fax: 706-653-1230
Mailing address:
  • Phone: 800-475-6112
  • Fax: 706-653-1230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number25MA05686200
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25MA05686200
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number062399L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: