Provider Demographics
NPI:1871632547
Name:FANTONE, EMMANUEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:EMMANUEL
Middle Name:J
Last Name:FANTONE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2778 E ECLIPSE AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-5475
Mailing Address - Country:US
Mailing Address - Phone:559-696-6968
Mailing Address - Fax:559-354-0167
Practice Address - Street 1:21900 BURBANK BLVD STE 300
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-7418
Practice Address - Country:US
Practice Address - Phone:818-992-3121
Practice Address - Fax:888-959-5641
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA491462084P0800X
CAA619072084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F21797Medicare UPIN