Provider Demographics
NPI:1609851690
Name:ANTONELLE, ROBERT W (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:ANTONELLE
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 1:311 NORTH ST
Mailing Address - Street 2:ROOM 403
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10605-2217
Mailing Address - Country:US
Mailing Address - Phone:914-949-7171
Mailing Address - Fax:914-949-7719
Practice Address - Street 1:311 NORTH ST
Practice Address - Street 2:ROOM 402
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10605-2217
Practice Address - Country:US
Practice Address - Phone:914-949-7171
Practice Address - Fax:914-949-7719
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-13
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY183668207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01355962Medicaid
F21221Medicare UPIN
NY27B791Medicare ID - Type Unspecified