Provider Demographics
NPI:1568503332
Name:ANTENUCCI, JUDITH (OD)
Entity type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:
Last Name:ANTENUCCI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 S OLD WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-6101
Mailing Address - Country:US
Mailing Address - Phone:248-723-1900
Mailing Address - Fax:248-723-8109
Practice Address - Street 1:160 S OLD WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009
Practice Address - Country:US
Practice Address - Phone:248-724-1900
Practice Address - Fax:248-723-1900
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004027152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU80741Medicare UPIN