Provider Demographics
NPI:1760642565
Name:ANTONOVA, VALENTINA MICHELLE (MD)
Entity Type:Individual
Prefix:
First Name:VALENTINA
Middle Name:MICHELLE
Last Name:ANTONOVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VALENTYNA
Other - Middle Name:MIKHAYLOVNA
Other - Last Name:ANTONOVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1561 LONG POND RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-4117
Mailing Address - Country:US
Mailing Address - Phone:585-723-7778
Mailing Address - Fax:585-723-7925
Practice Address - Street 1:1561 LONG POND RD
Practice Address - Street 2:SUITE 202
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4117
Practice Address - Country:US
Practice Address - Phone:585-723-7778
Practice Address - Fax:585-723-7925
Is Sole Proprietor?:No
Enumeration Date:2008-06-15
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY264605207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03433185Medicaid
NYJ400066774/GRPBA0017Medicare PIN
NYJ400066775/GRP70008AMedicare PIN