Provider Demographics
NPI:1437319019
Name:FANTARELLA, ELIZA (DPM)
Entity Type:Individual
Prefix:
First Name:ELIZA
Middle Name:
Last Name:FANTARELLA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:ELIZA
Other - Middle Name:
Other - Last Name:ADDIS-THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:330 ORCHARD ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511
Mailing Address - Country:US
Mailing Address - Phone:203-789-3152
Mailing Address - Fax:203-867-5457
Practice Address - Street 1:330 ORCHARD ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511
Practice Address - Country:US
Practice Address - Phone:203-789-3152
Practice Address - Fax:203-867-5457
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000867213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1437319019Medicaid
CTD400021459Medicare Oscar/Certification