Provider Demographics
NPI:1831218148
Name:ANTONELLI, MICHAEL (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:ANTONELLI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9127 W RUSSELL RD STE 110
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-1253
Mailing Address - Country:US
Mailing Address - Phone:702-878-0070
Mailing Address - Fax:702-209-2064
Practice Address - Street 1:1600 MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89703
Practice Address - Country:US
Practice Address - Phone:702-878-0070
Practice Address - Fax:702-209-2064
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVDO1734207L00000X, 207L00000X
CO51228207L00000X
TXP3280207L00000X
FLOS10636207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1831218148Medicaid
FLP00772722OtherRAILROAD MEDICARE
FL001398800Medicaid
FL001398800Medicaid