=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144161803
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIC FANTAUZZO CPED
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2026
-----------------------------------------------------
Last Update Date | 04/04/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2041 S CLINTON AVE
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14618-5704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-442-4990
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 184 ELMGROVE RD
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14626-4247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-794-1960
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224L00000X
-----------------------------------------------------
Taxonomy Name | Pedorthist
-----------------------------------------------------
License Number | CPED4962
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------