Provider Demographics
NPI:1659453967
Name:ANTANTA MEDICAL SPECIALISTS, INC
Entity Type:Organization
Organization Name:ANTANTA MEDICAL SPECIALISTS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:CUDE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:323-299-7508
Mailing Address - Street 1:311 N ROBERTSON BLVD # 692
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-1705
Mailing Address - Country:US
Mailing Address - Phone:323-299-7508
Mailing Address - Fax:323-299-9376
Practice Address - Street 1:4249 1/2 CRENSHAW BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-2536
Practice Address - Country:US
Practice Address - Phone:323-299-7508
Practice Address - Fax:323-299-9476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA56051207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherTAX ID