Basic Information
| Provider Information | |||||||||
| NPI: | 1114912052 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LESPINASSE | ||||||||
| FirstName: | ANTOINE | ||||||||
| MiddleName: | ALEXANDRA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DUVIVIER | ||||||||
| OtherFirstName: | ANTOINE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 194 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | MONTCLAIR | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070421914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9737460250 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1000 HADDONFIELD BERLIN RD | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | VOORHEES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080433520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567822212 | ||||||||
| FaxNumber: | 8567822266 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2005 | ||||||||
| LastUpdateDate: | 04/15/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 25MA07507600 | NJ | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080N0001X | 25MA07507600 | NJ | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0024945 | 05 | NJ | MEDICAID | 2085801 | 05 | MA | MEDICAID |