Provider Demographics
NPI:1588826796
Name:ANTONOPOULOU, MARIANNA (MD)
Entity Type:Individual
Prefix:
First Name:MARIANNA
Middle Name:
Last Name:ANTONOPOULOU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 TECHNOLOGY PKWY STE 440
Mailing Address - Street 2:
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17050-9413
Mailing Address - Country:US
Mailing Address - Phone:717-791-2540
Mailing Address - Fax:
Practice Address - Street 1:2005 TECHNOLOGY PKWY
Practice Address - Street 2:SUITE 440
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17050-9413
Practice Address - Country:US
Practice Address - Phone:717-791-2540
Practice Address - Fax:717-791-2549
Is Sole Proprietor?:No
Enumeration Date:2008-06-28
Last Update Date:2021-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09214900207RE0101X
PAMD454872207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103044692Medicaid
PA103044692Medicaid