Provider Demographics
NPI:1891897617
Name:VANNATTA, FRED CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:CHARLES
Last Name:VANNATTA
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 1:695 DUTCHESS TPKE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12603-6442
Mailing Address - Country:US
Mailing Address - Phone:888-647-5979
Mailing Address - Fax:845-454-3693
Practice Address - Street 1:695 DUTCHESS TPKE
Practice Address - Street 2:SUITE 105
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12603-6442
Practice Address - Country:US
Practice Address - Phone:888-647-5979
Practice Address - Fax:888-847-0818
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1414422085R0202X
NJ25MA076733002085R0202X
AZ316892085R0202X
CT0414482085R0202X
CAA235702085R0202X
PAMD041298E2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY906S9WQ111OtherMEDICARE
PAB14194Medicare UPIN