Provider Demographics
NPI:1487683793
Name:ANTONIOU, NIKOLAS J (MD)
Entity Type:Individual
Prefix:DR
First Name:NIKOLAS
Middle Name:J
Last Name:ANTONIOU
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 1:7900 ROLLINS RD STE 1100
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-1512
Mailing Address - Country:US
Mailing Address - Phone:847-356-3680
Mailing Address - Fax:
Practice Address - Street 1:7900 ROLLINS RD STE 1100
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-1512
Practice Address - Country:US
Practice Address - Phone:847-356-3680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-098315207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-098315OtherSTATE LICENSE
IL036-098315Medicaid
IL036-098315Medicaid
ILF300133991OtherMEDICARE PTAN