Provider Demographics
NPI:1851484067
Name:FROOM, FENTON E (MD)
Entity Type:Individual
Prefix:
First Name:FENTON
Middle Name:E
Last Name:FROOM
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 1:9007 SHAWN PARK PL
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-4830
Mailing Address - Country:US
Mailing Address - Phone:407-909-0351
Mailing Address - Fax:
Practice Address - Street 1:1503 W OAK ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4065
Practice Address - Country:US
Practice Address - Phone:800-330-1984
Practice Address - Fax:407-847-5137
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME36200261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD55018Medicare UPIN
FL47339Medicare ID - Type Unspecified