Provider Demographics
NPI:1467401935
Name:MONTICELLO, ANTHONY RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:RICHARD
Last Name:MONTICELLO
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:RR 1 BOX 1056
Mailing Address - Street 2:
Mailing Address - City:BRACKNEY
Mailing Address - State:PA
Mailing Address - Zip Code:18812-9703
Mailing Address - Country:US
Mailing Address - Phone:570-663-2801
Mailing Address - Fax:570-663-2362
Practice Address - Street 1:RR 1 BOX 1056
Practice Address - Street 2:
Practice Address - City:BRACKNEY
Practice Address - State:PA
Practice Address - Zip Code:18812-9703
Practice Address - Country:US
Practice Address - Phone:570-663-2801
Practice Address - Fax:570-663-2362
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY122579207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00562767Medicaid
53369BMedicare ID - Type Unspecified
NY00562767Medicaid
C58742Medicare UPIN