Provider Demographics
NPI:1205193422
Name:FANOUSE, JOHN A (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:A
Last Name:FANOUSE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:453 EMERSON LN
Mailing Address - Street 2:
Mailing Address - City:BERKELEY HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:07922-2309
Mailing Address - Country:US
Mailing Address - Phone:718-864-3892
Mailing Address - Fax:
Practice Address - Street 1:4802 10TH AVE
Practice Address - Street 2:MAIMONIDES MEDICAL CENTER
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-2462
Practice Address - Country:US
Practice Address - Phone:718-283-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-12
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MB10005200207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program