Provider Demographics
NPI:1033310412
Name:MARCANTONIO, DOMENICA (MD)
Entity Type:Individual
Prefix:
First Name:DOMENICA
Middle Name:
Last Name:MARCANTONIO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1090 NE 84TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33138-3420
Mailing Address - Country:US
Mailing Address - Phone:352-401-1000
Mailing Address - Fax:
Practice Address - Street 1:1431 SW 1ST AVE
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471
Practice Address - Country:US
Practice Address - Phone:352-401-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME111770207P00000X
VA0101245230207P00000X
VA0116018214390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004444400Medicaid
FL14J65OtherBCBS
VA1033310412Medicaid
FLFS764XMedicare PIN
FL14J65OtherBCBS
VA021399V21Medicare PIN