Provider Demographics
NPI:1205209939
Name:MALDONADO, ANTONIO (OTA)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:MALDONADO
Suffix:
Gender:M
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2017 W WOODLAND ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5913
Mailing Address - Country:US
Mailing Address - Phone:417-889-4800
Mailing Address - Fax:
Practice Address - Street 1:2017 W WOODLAND ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5913
Practice Address - Country:US
Practice Address - Phone:417-889-4800
Practice Address - Fax:417-889-0980
Is Sole Proprietor?:No
Enumeration Date:2015-11-03
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012026727224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant