Provider Demographics
NPI:1578658506
Name:FANARA, JOSEPH THOMAS (DPM)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:THOMAS
Last Name:FANARA
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 1:1617 TEMPLE LANE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61112-1045
Mailing Address - Country:US
Mailing Address - Phone:815-332-5222
Mailing Address - Fax:815-332-5223
Practice Address - Street 1:1617 TEMPLE LANE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61112-1045
Practice Address - Country:US
Practice Address - Phone:815-332-5222
Practice Address - Fax:815-332-5223
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-004607213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL993150Medicare PIN
IL6196610001Medicare NSC
ILU41699Medicare UPIN