MEDICARE: EWALD J. ANTOINE MD PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	167153	NY

General Provider Information

NPI Number	:	1043591746
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EWALD J. ANTOINE MD PC

Provider Business Mailing Address
First Line	:	1365 LEONARD WAY
Second Line	:
City	:	VALLEY STREAM
State	:	NY
Zip	:	11580-1556
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1546 DUTCH BROADWAY
Second Line	:
City	:	ELMONT
State	:	NY
Zip	:	11003-4522
Country	:	US
Telephone Number	:	516-256-0129
Fax Number	:

Authorized Official
Title or Position	:	MD
Name	:	EWALD ANTOINE
Credential	:
Telephone Number	:	516-644-6895

Provider Enumeration Date	:	09/08/2011
Last Update Date	:	09/08/2011

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