Provider Demographics
NPI:1700990355
Name:ANTONETTI, ILLENA (MD)
Entity Type:Individual
Prefix:
First Name:ILLENA
Middle Name:
Last Name:ANTONETTI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1723 LUCERNE TER STE 100
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2916
Mailing Address - Country:US
Mailing Address - Phone:407-738-4200
Mailing Address - Fax:407-650-1307
Practice Address - Street 1:7148 CURRY FORD RD STE 200
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-5803
Practice Address - Country:US
Practice Address - Phone:407-738-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2024-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME115814207RC0000X, 207RC0000X
NY252752208M00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHL455ZMedicare PIN
NYJ400003936Medicare PIN