Provider Demographics
NPI:1841263225
Name:FANTL, JOHN ANDREW (MD)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ANDREW
Last Name:FANTL
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:PO BOX 95000-2428
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19195-2428
Mailing Address - Country:US
Mailing Address - Phone:212-844-8521
Mailing Address - Fax:
Practice Address - Street 1:10 UNION SQ E FRNT 2E
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-3314
Practice Address - Country:US
Practice Address - Phone:212-844-8521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1988811207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY09G071Medicare PIN
B62314Medicare UPIN