Healthcare Provider Details

I. General information

NPI: 1104080639
Provider Name (Legal Business Name): ANTONY LESLIE INNASIMUTHU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2008
Last Update Date: 02/26/2020
Certification Date: 02/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 STANTON CHRISTIANA RD SUITE 203
NEWARK DE
19713-2133
US

IV. Provider business mailing address

620 STANTON CHRISTIANA RD SUITE 203
NEWARK DE
19713-2133
US

V. Phone/Fax

Practice location:
  • Phone: 302-338-9444
  • Fax: 302-338-9449
Mailing address:
  • Phone: 302-338-9444
  • Fax: 302-338-9449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberC1-0010967
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License NumberC1-0010967
License Number StateDE
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberC1-0010967
License Number StateDE
# 4
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberC1-0010967
License Number StateDE
# 5
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License NumberC1-0010967
License Number StateDE
# 6
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberC1-0010967
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: