Provider Demographics
NPI:1306905963
Name:ANTONIOLLI, ANITA LUCIA (MD)
Entity type:Individual
Prefix:MRS
First Name:ANITA
Middle Name:LUCIA
Last Name:ANTONIOLLI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANITA
Other - Middle Name:LUCIA
Other - Last Name:LEININGER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:29992 NORTHWESTERN HWY STE C
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-3292
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4967 CROOKS RD STE 210
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48098-5804
Practice Address - Country:US
Practice Address - Phone:248-687-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301061661208600000X
OH35080460208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH04502OtherPARAMOUNT
106485OtherNATIONWIDE
OH2422079Medicaid
106485OtherNATIONWIDE
OHLE4110251Medicare ID - Type Unspecified
OH2422079Medicaid