Provider Demographics
NPI:1750708822
Name:DR. THEODORE ANTONETZ, DPM, PC
Entity type:Organization
Organization Name:DR. THEODORE ANTONETZ, DPM, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTONETZ
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:212-877-3062
Mailing Address - Street 1:6 FRANCES DR
Mailing Address - Street 2:
Mailing Address - City:KATONAH
Mailing Address - State:NY
Mailing Address - Zip Code:10536-3211
Mailing Address - Country:US
Mailing Address - Phone:212-877-3062
Mailing Address - Fax:212-873-9521
Practice Address - Street 1:185 W END AVE
Practice Address - Street 2:SUITE 1N
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-5539
Practice Address - Country:US
Practice Address - Phone:212-877-3062
Practice Address - Fax:212-873-9521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-26
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01008924Medicaid
NYP43851Medicare UPIN