Provider Demographics
NPI:1285846071
Name:ANTOLIN, ELEANOR BANZON (MD)
Entity Type:Individual
Prefix:
First Name:ELEANOR
Middle Name:BANZON
Last Name:ANTOLIN
Suffix:
Gender:F
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:RR2 BOX 2440
Mailing Address - Street 2:
Mailing Address - City:CRESCO
Mailing Address - State:PA
Mailing Address - Zip Code:18326
Mailing Address - Country:US
Mailing Address - Phone:570-420-8601
Mailing Address - Fax:
Practice Address - Street 1:206 E BROWN ST
Practice Address - Street 2:
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301-3006
Practice Address - Country:US
Practice Address - Phone:570-421-4000
Practice Address - Fax:570-424-3346
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-061175-L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA017179400003Medicaid
PA017179400002Medicaid
PA017179400003Medicaid
PA017179400002Medicaid