Provider Demographics
NPI:1023103009
Name:ANTONETTI, ALFREDO RICARDO (MD)
Entity type:Individual
Prefix:DR
First Name:ALFREDO
Middle Name:RICARDO
Last Name:ANTONETTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ALFRED
Other - Middle Name:R
Other - Last Name:ANTONETTI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:6020 W. PLANO PKWY
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-4640
Mailing Address - Country:US
Mailing Address - Phone:469-429-7558
Mailing Address - Fax:469-429-2499
Practice Address - Street 1:6020 W. PLANO PKWY
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-4640
Practice Address - Country:US
Practice Address - Phone:469-429-7558
Practice Address - Fax:469-429-2499
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE1491208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX089482603Medicaid
TX0894826-01Medicaid
TX089482603Medicaid
TXC12895Medicare UPIN
TXB131669Medicare PIN
C12895Medicare UPIN