Healthcare Provider Details

I. General information

NPI: 1720069545
Provider Name (Legal Business Name): MIGUEL A ANTELO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 12/27/2022
Certification Date: 12/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 RIVERSIDE ST
NASHUA NH
03062-1304
US

IV. Provider business mailing address

PO BOX 3677
NASHUA NH
03061-3677
US

V. Phone/Fax

Practice location:
  • Phone: 603-577-3190
  • Fax: 603-577-3191
Mailing address:
  • Phone: 603-577-7900
  • Fax: 36-577-7972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number215883
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number15500
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: