Provider Demographics
NPI:1518902634
Name:AL-DEHNEH, ANTHONY (DO)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:AL-DEHNEH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 E. REDSTONE AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32539-5350
Mailing Address - Country:US
Mailing Address - Phone:850-682-7212
Mailing Address - Fax:850-682-6302
Practice Address - Street 1:129 E. REDSTONE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539-5350
Practice Address - Country:US
Practice Address - Phone:850-682-7212
Practice Address - Fax:850-682-6302
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS12174207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0170411Medicaid
NJ101610TS6Medicare PIN
NJ101610R2YMedicare ID - Type Unspecified
NJ073027Medicare ID - Type Unspecified
NJ0170411Medicaid