Provider Demographics
NPI:1174643688
Name:ANTONACOS, SPIRO
Entity Type:Individual
Prefix:
First Name:SPIRO
Middle Name:
Last Name:ANTONACOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 FOREST HILL RD
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-4518
Mailing Address - Country:US
Mailing Address - Phone:973-669-9888
Mailing Address - Fax:
Practice Address - Street 1:582 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-1936
Practice Address - Country:US
Practice Address - Phone:973-673-7700
Practice Address - Fax:973-674-3943
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00511900152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4997000Medicaid
NJU35715Medicare UPIN
NJ4997000Medicaid