Provider Demographics
NPI:1114018140
Name:SCANTLEBURY, MICHELE ANTOINETTE
Entity type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:ANTOINETTE
Last Name:SCANTLEBURY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:272 65TH ST APT 11F
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-6512
Mailing Address - Country:US
Mailing Address - Phone:646-724-0150
Mailing Address - Fax:
Practice Address - Street 1:212 BERRY ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11249-3922
Practice Address - Country:US
Practice Address - Phone:718-599-1202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208050208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01807414Medicaid
NYG65509Medicare UPIN
NY01807414Medicaid