Provider Demographics
NPI:1760429476
Name:ANTONIS, MICHAEL SEAN (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SEAN
Last Name:ANTONIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P. O. BOX 715868
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19171-5868
Mailing Address - Country:US
Mailing Address - Phone:804-215-3063
Mailing Address - Fax:804-968-1803
Practice Address - Street 1:20041 RIVERSIDE COMMONS PLAZA
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147
Practice Address - Country:US
Practice Address - Phone:703-466-0447
Practice Address - Fax:703-810-5313
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDO034203207P00000X
VA0102204828207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCP00858308OtherRAILROAD MEDICARE
ILK20717Medicare ID - Type Unspecified
DCP00858308OtherRAILROAD MEDICARE
DC019509M32Medicare PIN