Provider Demographics
NPI:1841290541
Name:ANTONUCCI, RICHARD ANGELO (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:ANGELO
Last Name:ANTONUCCI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:726 HAMPTON ROADS DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37934-4071
Mailing Address - Country:US
Mailing Address - Phone:865-675-1209
Mailing Address - Fax:865-675-1109
Practice Address - Street 1:7551 DANNAHER WAY
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:TN
Practice Address - Zip Code:37849-4029
Practice Address - Country:US
Practice Address - Phone:865-637-9330
Practice Address - Fax:865-859-7222
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000017010207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3021999Medicaid
TN4082085OtherBLUE CROSS BLUE SHIELD
TN4082085OtherBLUE CROSS BLUE SHIELD
TN3021999Medicaid
P00110921Medicare ID - Type UnspecifiedRR