Provider Demographics
NPI:1184781031
Name:ANTONETTI, DAVID (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:ANTONETTI
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 1:3348 MARTHA CUSTIS DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22302-2115
Mailing Address - Country:US
Mailing Address - Phone:703-893-6634
Mailing Address - Fax:
Practice Address - Street 1:1715 N GEORGE MASON DR
Practice Address - Street 2:SUITE 201
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22205-3609
Practice Address - Country:US
Practice Address - Phone:703-243-6122
Practice Address - Fax:703-243-0768
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101238073207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC024905300Medicaid
DCC87880Medicare UPIN