Provider Demographics
NPI:1134281116
Name:ANTILES, LEONARD (MD)
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:
Last Name:ANTILES
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 1:80 MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-4934
Mailing Address - Country:US
Mailing Address - Phone:973-736-9189
Mailing Address - Fax:
Practice Address - Street 1:GREYSTONE PARK PSYCHIATRIC HOSPITAL
Practice Address - Street 2:1 CENTRAL AVENUE
Practice Address - City:GREYSTONE PARK
Practice Address - State:NJ
Practice Address - Zip Code:07950
Practice Address - Country:US
Practice Address - Phone:973-292-4070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02133800208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ196546C2EOtherMEDICARE BILLING NO.
NJ123456C2DOtherMEDICARE BILLING NO.
NJAN196546Medicare ID - Type Unspecified
NJ196546C2EOtherMEDICARE BILLING NO.
NJC58226NJMedicare UPIN