Healthcare Provider Details

I. General information

NPI: 1730279670
Provider Name (Legal Business Name): ANTONELLA RESTIVO LEARY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 08/10/2022
Certification Date: 08/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 PGA BLVD. SUITE 200
PALM BEACH GARDENS FL
33410-2824
US

IV. Provider business mailing address

PO BOX 102222
ATLANTA GA
30368-2222
US

V. Phone/Fax

Practice location:
  • Phone: 561-366-4100
  • Fax: 561-776-8801
Mailing address:
  • Phone: 239-274-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberME114845
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: