1912285081 NPI number — MIGUEL R ANTONATOS M.D.

Table of content: MIGUEL R ANTONATOS M.D. (NPI 1912285081)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912285081 NPI number — MIGUEL R ANTONATOS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANTONATOS
Provider First Name:
MIGUEL
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912285081
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/24/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4803 N MILWAUKEE AVE
Provider Second Line Business Mailing Address:
SUITE B UNIT #220
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-847-2280
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4803 N MILWAUKEE AVE
Provider Second Line Business Practice Location Address:
SUITE B UNIT #220
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-847-2280
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/23/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  036138839 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: 036138839 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 036138839 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 12428 . This is a "SD LICENSE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: C0084 . This is a "KY LICENSE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: ME147653 . This is a "FL LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 30482 . This is a "WV LICENSE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 412-320 . This is a "WI LICENSE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 41925 . This is a "AL LICENSE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 61076 . This is a "AZ LICENSE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: C177591 . This is a "CA LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: D0090753 . This is a "MD LICENSE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: EMC0000064 . This is a "MI LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 28569 . This is a "MS LICENSE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 33242 . This is a "NE LICENSE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 036138839 . This is a "ILLIONOIS LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 04-44257 . This is a "KS LICENSE" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 20724 . This is a "NV LICENSE" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 42.0015135 . This is a "VT LICENSE" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 68586 . This is a "MN LICENSE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 85397 . This is a "GA LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 25MA10452000 . This is a "NJ LICENSE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: MD-47241 . This is a "IA LICENSE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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