Individual
EUGENE FANTL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
99 ASH ST, EAST HARTFORD, CT 06108-3226
(860) 282-3859
(860) 282-8574
Mailing address
65 KANE ST, PROVIDER ENROLLMENT, WEST HARTFORD, CT 06119-2110
(860) 523-6421
(860) 523-3701
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
019762
CT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1197623
—
CT
Enumeration date
06/22/2005
Last updated
07/15/2010
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