Provider Demographics
NPI:1609884667
Name:ANTONESCU WOLF, DAN (MD)
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:
Last Name:ANTONESCU WOLF
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 1:989 W JERICHO TPKE
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787
Mailing Address - Country:US
Mailing Address - Phone:631-864-7100
Mailing Address - Fax:631-864-7129
Practice Address - Street 1:989 W JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787
Practice Address - Country:US
Practice Address - Phone:631-864-7100
Practice Address - Fax:631-864-7129
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY152817207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00894564Medicaid
NY0118403OtherGHI
P00354563OtherRAILROAD MEDICARE
C07412Medicare UPIN
NYAN026D3310Medicare PIN
NY00894564Medicaid