MEDICARE: MR. THOMAS W FANTAUZZO C.PED

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224L00000X	Pedorthist
2	335E00000X	Prosthetic/Orthotic Supplier		NY

General Provider Information

NPI Number	:	1548570591
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. THOMAS W FANTAUZZO C.PED

Provider Business Mailing Address
First Line	:	46 CAPRI DR
Second Line	:	THOMAS FANTAUZZO
City	:	ROCHESTER
State	:	NY
Zip	:	14624-1357
Country	:	US
Telephone Number	:	585-247-7809
Fax Number	:

Provider Business Practice Location Address
First Line	:	1900 CLINTON AVE S
Second Line	:	FEET FIRST INC.
City	:	ROCHESTER
State	:	NY
Zip	:	14618-5621
Country	:	US
Telephone Number	:	585-442-4990
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/08/2010
Last Update Date	:	09/10/2014

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