Healthcare Provider Details

I. General information

NPI: 1699752634
Provider Name (Legal Business Name): ILEANA ANTONIADIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2005
Last Update Date: 03/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 ROUTE 71
SPRING LAKE NJ
07762-1875
US

IV. Provider business mailing address

207 ROUTE 71
SPRING LAKE NJ
07762-1875
US

V. Phone/Fax

Practice location:
  • Phone: 732-359-7232
  • Fax: 732-359-7233
Mailing address:
  • Phone: 732-359-7232
  • Fax: 732-359-7233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberMA 058058
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: