Provider Demographics
NPI:1730260175
Name:FANTONE, JOSEPH CARMINE III (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:CARMINE
Last Name:FANTONE
Suffix:III
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 918025
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-8025
Mailing Address - Country:US
Mailing Address - Phone:352-265-0237
Mailing Address - Fax:352-392-6249
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-265-0237
Practice Address - Fax:352-293-6249
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301043224207ZI0100X, 207ZP0101X
FLME108855207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
No207ZI0100XAllopathic & Osteopathic PhysiciansPathologyImmunopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003164400Medicaid
MI1443784Medicaid
FL003164400Medicaid
FLER701ZMedicare PIN
MIA79640Medicare UPIN