Provider Demographics
NPI:1104248517
Name:GARY A. FANTINI, M.D., PLLC
Entity type:Organization
Organization Name:GARY A. FANTINI, M.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CABEZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-606-1427
Mailing Address - Street 1:535 E 70TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4823
Mailing Address - Country:US
Mailing Address - Phone:212-606-1427
Mailing Address - Fax:212-774-7175
Practice Address - Street 1:535 E 70TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4823
Practice Address - Country:US
Practice Address - Phone:212-606-1427
Practice Address - Fax:212-774-7175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-21
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY161192-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty