Provider Demographics
NPI:1689607582
Name:ANTONIO, CORAZON GARCIA (MD)
Entity Type:Individual
Prefix:DR
First Name:CORAZON
Middle Name:GARCIA
Last Name:ANTONIO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 809
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46527-0809
Mailing Address - Country:US
Mailing Address - Phone:574-533-1234
Mailing Address - Fax:574-537-2652
Practice Address - Street 1:2399 E WALTON BLVD
Practice Address - Street 2:
Practice Address - City:AUBURN HILLS
Practice Address - State:MI
Practice Address - Zip Code:48326-1955
Practice Address - Country:US
Practice Address - Phone:248-475-2168
Practice Address - Fax:248-475-6403
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA373622084P0800X
IN01029237A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL268422500Medicaid
CAC25214Medicare UPIN