Provider Demographics
NPI:1619181369
Name:ANTONUCCI, JOHN VITO (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:VITO
Last Name:ANTONUCCI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:ATTN: PAYER CONTRACTING & RELATIONS
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:70 FULTON ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-2755
Practice Address - Country:US
Practice Address - Phone:248-338-0300
Practice Address - Fax:248-338-0663
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010817392085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP01013930OtherRAILROAD MEDICARE
MI9209246OtherAETNA THRU OAKLAND PHYSICIANS NETWORK SERVICES
MI200811OtherUNITED HEALTHCARE COMMUNITY PLAN
MI1046261OtherHEALTH PLUS OF MICHIGAN THRU OAKLAND PHYSICIANS NETWORK SERVICES (OPNS)