Provider Demographics
NPI:1508968843
Name:PUENTE, ANTONIO E (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:E
Last Name:PUENTE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1508 MILITARY CUTOFF ROAD
Mailing Address - Street 2:STE 303
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403
Mailing Address - Country:US
Mailing Address - Phone:910-509-9371
Mailing Address - Fax:910-509-9372
Practice Address - Street 1:1508 MILITARY CUTOFF ROAD
Practice Address - Street 2:STE 303
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403
Practice Address - Country:US
Practice Address - Phone:910-509-9371
Practice Address - Fax:910-509-9372
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC0831103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
04461OtherBCBS
04461OtherBCBS
2810371CMedicare ID - Type Unspecified