MEDICARE: ANTONELA MICCOLI M.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1144891508
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTONELA MICCOLI M.D

Provider Business Mailing Address
First Line	:	79-01 BROADWAY
Second Line	:
City	:	NEW YORK CITY
State	:	NY
Zip	:	11373
Country	:	US
Telephone Number	:	718-334-2156
Fax Number	:

Provider Business Practice Location Address
First Line	:	79-01 BROADWAY
Second Line	:
City	:	NEW YORK CITY
State	:	NY
Zip	:	11373
Country	:	US
Telephone Number	:	718-334-2156
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2021
Last Update Date	:	07/07/2021

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