Provider Demographics
NPI:1396852364
Name:FANN, THOMAS R (DPM)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
Last Name:FANN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 STATE RD 436
Mailing Address - Street 2:SUITE 1400
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707
Mailing Address - Country:US
Mailing Address - Phone:407-671-8010
Mailing Address - Fax:407-671-4155
Practice Address - Street 1:1120 STATE RD 436
Practice Address - Street 2:SUITE 1400
Practice Address - City:CASSELBERRY
Practice Address - State:FL
Practice Address - Zip Code:32707
Practice Address - Country:US
Practice Address - Phone:407-671-8010
Practice Address - Fax:407-671-4155
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO0001035213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL041060800Medicaid
87592Medicare ID - Type Unspecified
FL041060800Medicaid
T95154Medicare UPIN