Provider Demographics
NPI:1407852510
Name:ANTONATHENS, VICKI MARIA (DPM)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:MARIA
Last Name:ANTONATHENS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19723 ALLEN RD
Mailing Address - Street 2:BROWNSTOWN TWP
Mailing Address - City:BROWNSTOWN TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48183-1021
Mailing Address - Country:US
Mailing Address - Phone:734-479-8383
Mailing Address - Fax:734-479-8382
Practice Address - Street 1:19723 ALLEN RD
Practice Address - Street 2:BROWNSTOWN TWP
Practice Address - City:BROWNSTOWN TWP
Practice Address - State:MI
Practice Address - Zip Code:48183-1021
Practice Address - Country:US
Practice Address - Phone:734-479-8383
Practice Address - Fax:734-479-8382
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001086213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1701904Medicaid
MI1254620001Medicare NSC
MI1701904Medicaid
MIT34333Medicare UPIN