Healthcare Provider Details

I. General information

NPI: 1467847582
Provider Name (Legal Business Name): NINA KATHERINE ANTONOV M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2015
Last Update Date: 01/16/2022
Certification Date: 01/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1032 POST RD E
WESTPORT CT
06880-5369
US

IV. Provider business mailing address

1032 POST RD E
WESTPORT CT
06880-5369
US

V. Phone/Fax

Practice location:
  • Phone: 203-635-0770
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number67336
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: