Provider Demographics
NPI:1780683128
Name:ANTONOWICZ, MICHELLE (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:ANTONOWICZ
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 1:28 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CALDWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07006-4750
Mailing Address - Country:US
Mailing Address - Phone:973-396-8490
Mailing Address - Fax:
Practice Address - Street 1:1 BAY AVE
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-4837
Practice Address - Country:US
Practice Address - Phone:973-429-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2008-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07150800207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ045292OtherMEDICARE
NJ8398607Medicaid
NJ8398607Medicaid
H31313Medicare UPIN