Provider Demographics
NPI:1750456398
Name:ANTONINO, JEROME JOSEPH (DC)
Entity type:Individual
Prefix:DR
First Name:JEROME
Middle Name:JOSEPH
Last Name:ANTONINO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9707 158TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOWARD BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11414-3247
Mailing Address - Country:US
Mailing Address - Phone:718-835-7102
Mailing Address - Fax:
Practice Address - Street 1:15705 CROSSBAY BLVD
Practice Address - Street 2:
Practice Address - City:HOWARD BEACH
Practice Address - State:NY
Practice Address - Zip Code:11414-2748
Practice Address - Country:US
Practice Address - Phone:718-845-5252
Practice Address - Fax:718-845-6464
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX0045148111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYT31985Medicare UPIN