Provider Demographics
NPI:1316929524
Name:ANTONACCI, ANTHONY (MD)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:ANTONACCI
Suffix:
Gender:M
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:PO BOX 32936
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06150-2936
Mailing Address - Country:US
Mailing Address - Phone:212-256-3539
Mailing Address - Fax:
Practice Address - Street 1:130 E 77TH ST
Practice Address - Street 2:13 FL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-1851
Practice Address - Country:US
Practice Address - Phone:212-434-3420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY135626208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00844293Medicaid
C04407Medicare UPIN
NY00844293Medicaid