Provider Demographics
NPI:1255380812
Name:IANNELLO, ANTONINO EDMOND (PT)
Entity type:Individual
Prefix:MR
First Name:ANTONINO
Middle Name:EDMOND
Last Name:IANNELLO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 AUGUSTA DR STE 155
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77057-4922
Mailing Address - Country:US
Mailing Address - Phone:713-622-2929
Mailing Address - Fax:713-622-2922
Practice Address - Street 1:2400 AUGUSTA DR STE 155
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77057-4922
Practice Address - Country:US
Practice Address - Phone:713-622-2929
Practice Address - Fax:713-622-2922
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1149730225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F3614Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE NUMBE
TX00W860Medicare ID - Type UnspecifiedGROUP NUMBER