Provider Demographics
NPI:1710050034
Name:MICHELL, ANTONIO T (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:T
Last Name:MICHELL
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 1:2101 E JEFFERSON ST
Mailing Address - Street 2:KAISER PERMANENTE MEDICARE ENROLLMENT
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-2424
Mailing Address - Fax:
Practice Address - Street 1:201 N WASHINGTON ST FL 3
Practice Address - Street 2:KAISER PERMANENTE FALLS CHURCH MEDICAL CENTER
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-4518
Practice Address - Country:US
Practice Address - Phone:703-237-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101042792208800000X
DCMD13322208800000X
MDD0036953208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA34698Medicaid
E22171Medicare UPIN
VA34698Medicaid