Provider Demographics
NPI:1093958050
Name:LUIS, ANTONIO (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:
Last Name:LUIS
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 1:1013 FERNWOOD DR
Mailing Address - Street 2:STE B
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-5428
Mailing Address - Country:US
Mailing Address - Phone:478-251-6924
Mailing Address - Fax:478-295-3644
Practice Address - Street 1:1013 FERNWOOD DR
Practice Address - Street 2:STE B
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-5428
Practice Address - Country:US
Practice Address - Phone:478-251-6924
Practice Address - Fax:478-295-3644
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-07
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA235792084P0800X
GA0237592084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA023759OtherLICENSE #