Provider Demographics
NPI:1558410498
Name:FANTON, GARY STEVEN (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:STEVEN
Last Name:FANTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 PASTEUR DR
Mailing Address - Street 2:
Mailing Address - City:STANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:94305-2200
Mailing Address - Country:US
Mailing Address - Phone:650-723-4000
Mailing Address - Fax:650-736-9590
Practice Address - Street 1:300 PASTEUR DR
Practice Address - Street 2:
Practice Address - City:STANFORD
Practice Address - State:CA
Practice Address - Zip Code:94305-2200
Practice Address - Country:US
Practice Address - Phone:650-723-4000
Practice Address - Fax:650-736-9590
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2024-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG45737207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA50164Medicare UPIN