Provider Demographics
NPI:1548265374
Name:ANTONELLO, ANTHONY JR (MD)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:
Last Name:ANTONELLO
Suffix:JR
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 1:1098 W BALTIMORE PIKE
Mailing Address - Street 2:SUITE 3302
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-5139
Mailing Address - Country:US
Mailing Address - Phone:610-565-6780
Mailing Address - Fax:610-565-9390
Practice Address - Street 1:1098 W BALTIMORE PIKE
Practice Address - Street 2:SUITE 3302
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-5139
Practice Address - Country:US
Practice Address - Phone:610-565-6780
Practice Address - Fax:610-565-9390
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-044041-E207W00000X
PAMD044041E207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001174031Medicaid
PAE42724Medicare UPIN
PA421172Medicare ID - Type UnspecifiedINDIVIDUAL