Healthcare Provider Details

I. General information

NPI: 1205078201
Provider Name (Legal Business Name): TODD JOSEPH ANTENUCCI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2009
Last Update Date: 12/15/2021
Certification Date: 12/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 W 158TH ST
NEW YORK NY
10032-7104
US

IV. Provider business mailing address

401 BICENTENNIAL WAY
SANTA ROSA CA
95403-2149
US

V. Phone/Fax

Practice location:
  • Phone: 212-544-1881
  • Fax:
Mailing address:
  • Phone: 707-393-4044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A12310
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: