Provider Demographics
NPI:1376678375
Name:MORTELLITI, ANTONIA (OD)
Entity Type:Individual
Prefix:DR
First Name:ANTONIA
Middle Name:
Last Name:MORTELLITI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:TONIA
Other - Middle Name:
Other - Last Name:MORTELLITI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:52 E 72 ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021
Mailing Address - Country:US
Mailing Address - Phone:212-439-9775
Mailing Address - Fax:212-439-0796
Practice Address - Street 1:52 EAST 72 ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021
Practice Address - Country:US
Practice Address - Phone:212-439-9775
Practice Address - Fax:212-439-0796
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV0045231152W00000X
CT002077152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY561621OtherAETNA
NY561621OtherAETNA
U59412Medicare UPIN