Provider Demographics
NPI:1205830742
Name:ANTONICO, JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:
Last Name:ANTONICO
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 1:388 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:CT
Mailing Address - Zip Code:06468-1150
Mailing Address - Country:US
Mailing Address - Phone:203-459-0191
Mailing Address - Fax:203-459-0192
Practice Address - Street 1:388 MAIN ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:CT
Practice Address - Zip Code:06468-1150
Practice Address - Country:US
Practice Address - Phone:203-459-0191
Practice Address - Fax:203-459-0192
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT028415207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTE06678Medicare UPIN
CT110002827Medicare ID - Type Unspecified