Provider Demographics
NPI:1619389053
Name:ANTONELLIS, ANNE LORETTA (MD)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:LORETTA
Last Name:ANTONELLIS
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 1:725 CONCORD AVE STE 1200
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-1055
Mailing Address - Country:US
Mailing Address - Phone:617-926-2414
Mailing Address - Fax:
Practice Address - Street 1:725 CONCORD AVE STE 1200
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138
Practice Address - Country:US
Practice Address - Phone:617-926-2414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-20
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEEC141074207V00000X
MA276409207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology