Provider Demographics
NPI:1043486236
Name:BACA, ANTONIO (MD)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:BACA
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 1:5705 FAIRFAX DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22205-2305
Mailing Address - Country:US
Mailing Address - Phone:216-288-1596
Mailing Address - Fax:
Practice Address - Street 1:2300 OPITZ BLVD
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3311
Practice Address - Country:US
Practice Address - Phone:216-288-1596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-07
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101250082207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine