Provider Demographics
NPI:1760490759
Name:ANTENUCCI, MARK DAVID (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DAVID
Last Name:ANTENUCCI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 WEST COUNTRY CLUB RD.
Mailing Address - Street 2:STE. 7
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201
Mailing Address - Country:US
Mailing Address - Phone:575-624-2398
Mailing Address - Fax:575-624-0655
Practice Address - Street 1:313 WEST COUNTRY CLUB RD.
Practice Address - Street 2:STE. 7
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201
Practice Address - Country:US
Practice Address - Phone:575-624-2398
Practice Address - Fax:575-624-0655
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM184213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM55657Medicaid
T41065Medicare UPIN
NM55657Medicaid
NMT41065Medicare PIN