Provider Demographics
NPI:1093741548
Name:ANTAO, OLAVIO A (MD)
Entity Type:Individual
Prefix:
First Name:OLAVIO
Middle Name:A
Last Name:ANTAO
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 1:135 CORPORATE WOODS STE 200C
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-1459
Mailing Address - Country:US
Mailing Address - Phone:585-784-7848
Mailing Address - Fax:585-784-7844
Practice Address - Street 1:135 CORPORATE WOODS STE 200C
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623
Practice Address - Country:US
Practice Address - Phone:585-784-7848
Practice Address - Fax:585-784-7844
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY158866207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5535346OtherAETNA
NY00864640Medicaid
NY00864640Medicaid
NYBB9949Medicare PIN