Provider Demographics
NPI:1447226261
Name:FANTASIA, MICHELE E (MD)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:E
Last Name:FANTASIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:150 NEW PROVIDENCE RD
Mailing Address - Street 2:
Mailing Address - City:MOUNTAINSIDE
Mailing Address - State:NJ
Mailing Address - Zip Code:07092-2590
Mailing Address - Country:US
Mailing Address - Phone:908-301-5404
Mailing Address - Fax:908-301-5456
Practice Address - Street 1:200 SOMERSET ST
Practice Address - Street 2:
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-1942
Practice Address - Country:US
Practice Address - Phone:732-258-7000
Practice Address - Fax:908-301-5456
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA063368002081P0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ221487148OtherDEVON HEALTHCARE
NJ01000313201OtherAMERICHOICE NJ
NJ1096732OtherHORIZON NJ HEALTH
NJ2119078000OtherAMERIHEALTH
NJ221487148OtherUNITED HEALTHCARE
NJS51B01OtherEMPIRE
NJ0125682OtherCIGNA HEALTHCARE
NJP2122543OtherOXFORD
NJ2K3684OtherHEALTHNET
NJ54027OtherAMERIGROUP
NJ221487148OtherMULTIPLAN
NJ2300074OtherAETNA HEALTHCARE
NJ24225OtherUNIVERSITY HEALTH PLAN
NJ221487148OtherGREAT WEST
NJ221487148OtherHORIZON BCBS NJ
NJ221487148-016OtherQUALCARE INC
NJ2300074OtherAETNA HEALTHCARE