Healthcare Provider Details

I. General information

NPI: 1548624372
Provider Name (Legal Business Name): MARK D ANTENUCCI DPM PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2016
Last Update Date: 04/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 W COUNTRY CLUB RD SUITE 7
ROSWELL NM
88201-5804
US

IV. Provider business mailing address

313 W COUNTRY CLUB RD SUITE 7
ROSWELL NM
88201-5804
US

V. Phone/Fax

Practice location:
  • Phone: 575-624-2398
  • Fax: 575-624-0655
Mailing address:
  • Phone: 575-624-2398
  • Fax: 575-624-0655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: MRS. CRISTINA ANTENUCCI
Title or Position: OFFICE MANAGER
Credential:
Phone: 575-624-2398