Provider Demographics
NPI:1679653448
Name:J ANDREW FANTL GYNECOLOGY PC
Entity Type:Organization
Organization Name:J ANDREW FANTL GYNECOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:FANTL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-979-2842
Mailing Address - Street 1:222 MIDDLE COUNTRY RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787
Mailing Address - Country:US
Mailing Address - Phone:631-979-2842
Mailing Address - Fax:631-979-2845
Practice Address - Street 1:222 MIDDLE COUNTRY RD
Practice Address - Street 2:SUITE 203
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787
Practice Address - Country:US
Practice Address - Phone:631-979-2842
Practice Address - Fax:631-979-2845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1988811207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
9658042OtherGHI
5817720OtherCIGNA
665C41OtherBCBS
198881OtherHIP
53073OtherVYTRA
P1935301OtherOXFORD
P62326327OtherMULTIPLAN
AA50860OtherMDNY
P1935301OtherOXFORD
AA50860OtherMDNY