Provider Demographics
NPI:1043256118
Name:ANTONEVICH, IVAN (MD)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:
Last Name:ANTONEVICH
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 1:1729 BURRSTONE RD
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-1001
Mailing Address - Country:US
Mailing Address - Phone:315-798-1567
Mailing Address - Fax:315-798-1565
Practice Address - Street 1:1729 BURRSTONE RD
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-1001
Practice Address - Country:US
Practice Address - Phone:315-798-1567
Practice Address - Fax:315-798-1565
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY229252208VP0014X
FLME90635207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2729598-00Medicaid
FL2729598-00Medicaid
FL16629Medicare ID - Type Unspecified