Healthcare Provider Details

I. General information

NPI: 1508967951
Provider Name (Legal Business Name): JOHN ANTONUCCI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 WILLARD AVE
NEWINGTON CT
06111-2631
US

IV. Provider business mailing address

11 WOODCHUCK HILL RD
CANTON CT
06019-2132
US

V. Phone/Fax

Practice location:
  • Phone: 860-677-6747
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number09502
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: