Provider Demographics
NPI:1811007743
Name:ANTONUCCI, ANTHONY J (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:J
Last Name:ANTONUCCI
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 1:6 HENNESSEY DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-3824
Mailing Address - Country:US
Mailing Address - Phone:631-827-6689
Mailing Address - Fax:631-673-4936
Practice Address - Street 1:830 PARK AVE
Practice Address - Street 2:CARILLON NURSING AND REHABILITATION CENTER
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-4543
Practice Address - Country:US
Practice Address - Phone:631-827-6689
Practice Address - Fax:631-673-4936
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY170689207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01048177Medicaid
019AY1Medicare ID - Type Unspecified
NY01048177Medicaid