Provider Demographics
NPI:1689073819
Name:ANTOINE, GARRY B (MD)
Entity Type:Individual
Prefix:DR
First Name:GARRY
Middle Name:B
Last Name:ANTOINE
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:PO BOX 951306
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32795-1306
Mailing Address - Country:US
Mailing Address - Phone:407-602-1100
Mailing Address - Fax:407-219-4221
Practice Address - Street 1:5844 N ORANGE BLOSSOM TRL
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32810-1025
Practice Address - Country:US
Practice Address - Phone:407-602-1100
Practice Address - Fax:407-219-4221
Is Sole Proprietor?:No
Enumeration Date:2014-08-13
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR18854208D00000X
FLACN675208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015253600Medicaid