Provider Demographics
NPI:1790761245
Name:ANTONIOUS, GEORGE B (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:B
Last Name:ANTONIOUS
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 1:8333 N DAVIS HWY FL 2
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-6050
Mailing Address - Country:US
Mailing Address - Phone:850-474-8121
Mailing Address - Fax:850-474-8096
Practice Address - Street 1:8333 N DAVIS HWY FL 2
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-6050
Practice Address - Country:US
Practice Address - Phone:850-474-8121
Practice Address - Fax:850-474-8096
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82874207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL01187OtherBLUE CROSS BLUE SHIELD
FL261961000Medicaid
AL591-83784OtherBLUE CROSS BLUE SHIELD
AL009935446Medicaid
7167253OtherAETNA
FL01187YMedicare ID - Type Unspecified
FL261961000Medicaid
AL009935446Medicaid