Provider Demographics
NPI:1053677047
Name:LOZADA, ANTONIO DESEAN
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:DESEAN
Last Name:LOZADA
Suffix:
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:PO BOX 3988
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-3988
Mailing Address - Country:US
Mailing Address - Phone:618-457-5200
Mailing Address - Fax:
Practice Address - Street 1:305 W JACKSON ST STE 206
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1474
Practice Address - Country:US
Practice Address - Phone:618-457-3006
Practice Address - Fax:618-457-3008
Is Sole Proprietor?:No
Enumeration Date:2012-04-04
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361454682086S0127X
IL036.1464962086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery