Provider Demographics
NPI:1104080639
Name:INNASIMUTHU, ANTONY LESLIE (MD)
Entity type:Individual
Prefix:DR
First Name:ANTONY
Middle Name:LESLIE
Last Name:INNASIMUTHU
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:620 STANTON CHRISTIANA RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2133
Mailing Address - Country:US
Mailing Address - Phone:302-338-9444
Mailing Address - Fax:302-338-9449
Practice Address - Street 1:620 STANTON CHRISTIANA RD
Practice Address - Street 2:SUITE 203
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2133
Practice Address - Country:US
Practice Address - Phone:302-338-9444
Practice Address - Fax:302-338-9449
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-14
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
DEC1-0010967207RI0011X, 207UN0901X, 2085R0204X, 261QM2500X, 282N00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1104080639Medicaid