Provider Demographics
NPI:1396701769
Name:ANTISDEL, THOMAS J (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:J
Last Name:ANTISDEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:44 BIRCH ST
Mailing Address - Street 2:STE 200
Mailing Address - City:DERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03038-2752
Mailing Address - Country:US
Mailing Address - Phone:603-421-2526
Mailing Address - Fax:603-421-2568
Practice Address - Street 1:44 BIRCH ST
Practice Address - Street 2:STE 200
Practice Address - City:DERRY
Practice Address - State:NH
Practice Address - Zip Code:03038-2752
Practice Address - Country:US
Practice Address - Phone:603-421-2526
Practice Address - Fax:603-421-2568
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NH6965207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3078313Medicaid
NH3078313Medicaid
NHD78683Medicare UPIN
NHP01789750Medicare PIN