Provider Demographics
NPI:1023112604
Name:PANTANO, PAUL JOSEPH II (DPM)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:JOSEPH
Last Name:PANTANO
Suffix:II
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 540326
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02454
Mailing Address - Country:US
Mailing Address - Phone:781-893-1443
Mailing Address - Fax:781-231-9320
Practice Address - Street 1:32 SOUTH ST
Practice Address - Street 2:SUITE 300A
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453
Practice Address - Country:US
Practice Address - Phone:781-893-1443
Practice Address - Fax:781-231-9320
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-12
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1547213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0340855Medicaid
MA0340855Medicaid
Y70637Medicare ID - Type Unspecified