Provider Demographics
NPI:1508967951
Name:ANTONUCCI, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:ANTONUCCI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 WOODCHUCK HILL RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:CT
Mailing Address - Zip Code:06019-2132
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:555 WILLARD AVE
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-2631
Practice Address - Country:US
Practice Address - Phone:860-677-6747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT095022084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine