Provider Demographics
NPI:1548570591
Name:FANTAUZZO, THOMAS W (CPED)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:W
Last Name:FANTAUZZO
Suffix:
Gender:M
Credentials:CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:46 CAPRI DR
Mailing Address - Street 2:THOMAS FANTAUZZO
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14624-1357
Mailing Address - Country:US
Mailing Address - Phone:585-247-7809
Mailing Address - Fax:
Practice Address - Street 1:1900 CLINTON AVE S
Practice Address - Street 2:FEET FIRST INC.
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-5621
Practice Address - Country:US
Practice Address - Phone:585-442-4990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-08
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224L00000X
NY335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist