Provider Demographics
NPI:1588637896
Name:FANNEY, DAVID GRAFTON (DO)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:GRAFTON
Last Name:FANNEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4241 NW AMERICAN LANE
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055
Mailing Address - Country:US
Mailing Address - Phone:386-752-2246
Mailing Address - Fax:386-758-7998
Practice Address - Street 1:4241 NW AMERICAN LANE
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055
Practice Address - Country:US
Practice Address - Phone:386-752-2246
Practice Address - Fax:386-758-7998
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2009-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0005960207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL051724100Medicaid
E50194Medicare UPIN
FL80408AMedicare ID - Type Unspecified