Provider Demographics
NPI:1902110455
Name:ANTONELLI, ANDREA B (OD)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:B
Last Name:ANTONELLI
Suffix:
Gender:F
Credentials:OD
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Other - Credentials:
Mailing Address - Street 1:760 BROADWAY DEPARTMENT OF MANAGED CARE ROOM 2B230
Mailing Address - Street 2:WOODHULL MEDICAL AND MENTAL HEALTH CENTER
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11206
Mailing Address - Country:US
Mailing Address - Phone:718-963-8000
Mailing Address - Fax:718-630-3122
Practice Address - Street 1:760 BROADWAY
Practice Address - Street 2:WOODHULL MEDICAL AND MENTAL HEALTH CENTER
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206
Practice Address - Country:US
Practice Address - Phone:718-963-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-27
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007489-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist