Provider Demographics
NPI:1730279670
Name:LEARY, ANTONELLA RESTIVO (MD)
Entity Type:Individual
Prefix:
First Name:ANTONELLA
Middle Name:RESTIVO
Last Name:LEARY
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:PO BOX 102222
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2222
Mailing Address - Country:US
Mailing Address - Phone:239-274-8200
Mailing Address - Fax:
Practice Address - Street 1:3401 PGA BLVD.
Practice Address - Street 2:SUITE 200
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-2824
Practice Address - Country:US
Practice Address - Phone:561-366-4100
Practice Address - Fax:561-776-8801
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME114845207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016293900Medicaid
FLGA620YMedicare PIN