Provider Demographics
NPI:1568787794
Name:ANTOS, NICHOLAS J (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:J
Last Name:ANTOS
Suffix:
Gender:M
Credentials:MD
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:PEDIATRIC PULMONARY MEDICINE
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-6730
Mailing Address - Fax:414-266-6742
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:PEDIATRIC PULMONARY MEDICINE
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-266-6730
Practice Address - Fax:414-266-6742
Is Sole Proprietor?:No
Enumeration Date:2010-03-31
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI54265208000000X, 2080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1568787794Medicaid