MEDICARE: DR. JOSEPH ANTONICO 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	207R00000X	Internal Medicine Physician	028415	CT

General Provider Information

NPI Number	:	1205830742
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOSEPH ANTONICO M.D.

Provider Business Mailing Address
First Line	:	388 MAIN ST
Second Line	:
City	:	MONROE
State	:	CT
Zip	:	06468-1150
Country	:	US
Telephone Number	:	203-459-0191
Fax Number	:	203-459-0192

Provider Business Practice Location Address
First Line	:	388 MAIN ST
Second Line	:
City	:	MONROE
State	:	CT
Zip	:	06468-1150
Country	:	US
Telephone Number	:	203-459-0191
Fax Number	:	203-459-0192

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

Provider Enumeration Date	:	06/13/2005
Last Update Date	:	01/21/2010

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