Provider Demographics
NPI:1447319702
Name:ECLAVEA, ANTHONY (MD)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:ECLAVEA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91-1051 FRANKLIN D ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:KAPOLEI
Mailing Address - State:HI
Mailing Address - Zip Code:96707-2185
Mailing Address - Country:US
Mailing Address - Phone:800-214-1306
Mailing Address - Fax:
Practice Address - Street 1:91-1051 FRANKLIN D ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:KAPOLEI
Practice Address - State:HI
Practice Address - Zip Code:96707-2185
Practice Address - Country:US
Practice Address - Phone:800-214-1306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI503672085R0204X
GA503612085R0204X
HIMD-98822085R0204X, 2085R0202X
IN01051628A2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34785300Medicaid
WI34785300Medicaid