Provider Demographics
NPI:1417499310
Name:ANTONY, MINIMOL
Entity Type:Individual
Prefix:
First Name:MINIMOL
Middle Name:
Last Name:ANTONY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2107 DITMAS AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-6903
Mailing Address - Country:US
Mailing Address - Phone:718-262-8100
Mailing Address - Fax:929-264-5950
Practice Address - Street 1:2107 DITMAS AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-6903
Practice Address - Country:US
Practice Address - Phone:718-226-8100
Practice Address - Fax:929-264-5950
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-08
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY301356208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program