Provider Demographics
NPI:1417536400
Name:PALAU ANTILLON, ROBERTA (MD)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:
Last Name:PALAU ANTILLON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1041 GLENDON AVE APT 4205
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-2938
Mailing Address - Country:US
Mailing Address - Phone:850-512-2466
Mailing Address - Fax:
Practice Address - Street 1:14400 OLIVE VIEW DR
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-1436
Practice Address - Country:US
Practice Address - Phone:850-512-2466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program