Provider Demographics
NPI:1083714554
Name:ANTONETZ, THEODORE (DPM)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:
Last Name:ANTONETZ
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 WEST END AVENUE
Mailing Address - Street 2:SUITE 1N
Mailing Address - City:NYC
Mailing Address - State:NY
Mailing Address - Zip Code:10023
Mailing Address - Country:US
Mailing Address - Phone:212-877-3062
Mailing Address - Fax:
Practice Address - Street 1:185 WEST END AVENUE
Practice Address - Street 2:SUITE 1N
Practice Address - City:NYC
Practice Address - State:NY
Practice Address - Zip Code:10023
Practice Address - Country:US
Practice Address - Phone:212-877-3062
Practice Address - Fax:212-873-9521
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004056213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP43851OtherBLUE CROSS/BLUE SHIELD
NYP43851OtherBLUE CROSS/BLUE SHIELD