Provider Demographics
NPI:1275919268
Name:ANTONUCCI, BENJAMIN Q (PT)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:Q
Last Name:ANTONUCCI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 LONG POND RD
Mailing Address - Street 2:104
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-1177
Mailing Address - Country:US
Mailing Address - Phone:585-697-0207
Mailing Address - Fax:585-697-0209
Practice Address - Street 1:1100 LONG POND RD
Practice Address - Street 2:104
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-1177
Practice Address - Country:US
Practice Address - Phone:585-697-0207
Practice Address - Fax:585-697-0209
Is Sole Proprietor?:No
Enumeration Date:2015-08-03
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038968225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist