Provider Demographics
NPI:1902110455
Name:ANTONELLI, ANDREA B (OD)
Entity type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:B
Last Name:ANTONELLI
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 1:547 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07043-1880
Mailing Address - Country:US
Mailing Address - Phone:973-783-6446
Mailing Address - Fax:973-783-6448
Practice Address - Street 1:547 VALLEY RD
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07043-1880
Practice Address - Country:US
Practice Address - Phone:973-783-6446
Practice Address - Fax:973-783-6448
Is Sole Proprietor?:No
Enumeration Date:2010-07-27
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007489-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist