Provider Demographics
NPI:1679541973
Name:ANTARIS, LEONARDO MIGUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:LEONARDO
Middle Name:MIGUEL
Last Name:ANTARIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1230 E RUSHOLME ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803-2400
Mailing Address - Country:US
Mailing Address - Phone:563-326-8181
Mailing Address - Fax:563-326-8184
Practice Address - Street 1:1230 E RUSHOLME ST
Practice Address - Street 2:SUITE 107
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-2400
Practice Address - Country:US
Practice Address - Phone:563-326-8181
Practice Address - Fax:563-326-8184
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA27394207W00000X
IL036092359207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0293464Medicaid
IAE42658Medicare UPIN
IA0293464Medicaid