Provider Demographics
NPI:1407864093
Name:ANTOO, ALBY K (MD)
Entity Type:Individual
Prefix:DR
First Name:ALBY
Middle Name:K
Last Name:ANTOO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ALBY
Other - Middle Name:A
Other - Last Name:KACHAPPILLY
Other - Suffix:
Other - Last Name Type:Doing Business As
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-647-6326
Mailing Address - Fax:
Practice Address - Street 1:10400 75TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142
Practice Address - Country:US
Practice Address - Phone:262-948-6740
Practice Address - Fax:262-948-6721
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-113334207Q00000X
WI48314207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34661500Medicaid