Provider Demographics
NPI:1003554759
Name:ABANTAO, JOHN MALACAD JR
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MALACAD
Last Name:ABANTAO
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 E 13TH ST
Mailing Address - Street 2:
Mailing Address - City:GIBSON CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60936-1104
Mailing Address - Country:US
Mailing Address - Phone:929-213-5523
Mailing Address - Fax:
Practice Address - Street 1:1001 E PELLS ST
Practice Address - Street 2:
Practice Address - City:PAXTON
Practice Address - State:IL
Practice Address - Zip Code:60957-1300
Practice Address - Country:US
Practice Address - Phone:217-379-4361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-23
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040925-01225100000X
IL070.024114225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist