Provider Demographics
NPI:1346394772
Name:FATA, JOHN G (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:G
Last Name:FATA
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1500 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EATON RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:48827-1952
Mailing Address - Country:US
Mailing Address - Phone:517-663-9555
Mailing Address - Fax:517-663-3430
Practice Address - Street 1:1500 S MAIN ST
Practice Address - Street 2:
Practice Address - City:EATON RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:48827-1952
Practice Address - Country:US
Practice Address - Phone:517-663-9555
Practice Address - Fax:517-663-3430
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301061176207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIF56618Medicare UPIN
MIC37612015Medicare PIN