Provider Demographics
NPI:1992098123
Name:FANTRY, AMANDA (MD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:FANTRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 ASYLUM AVE STE 2126
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-1718
Mailing Address - Country:US
Mailing Address - Phone:860-728-6740
Mailing Address - Fax:860-547-1554
Practice Address - Street 1:1000 ASYLUM AVE STE 2126
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105
Practice Address - Country:US
Practice Address - Phone:860-728-6740
Practice Address - Fax:860-547-1554
Is Sole Proprietor?:No
Enumeration Date:2011-05-20
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD15395207X00000X
CT61342207XX0004X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery