Provider Demographics
NPI:1881818292
Name:MADRID, ANTONIO (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:
Last Name:MADRID
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 519
Mailing Address - Street 2:
Mailing Address - City:MONTE RIO
Mailing Address - State:CA
Mailing Address - Zip Code:95462-0519
Mailing Address - Country:US
Mailing Address - Phone:707-865-1200
Mailing Address - Fax:707-865-3151
Practice Address - Street 1:BOX 519
Practice Address - Street 2:19375 HIGHWAY 116
Practice Address - City:MONTE RIO
Practice Address - State:CA
Practice Address - Zip Code:95462-0519
Practice Address - Country:US
Practice Address - Phone:707-865-1200
Practice Address - Fax:707-865-3151
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPL3970103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PL39700Medicare ID - Type Unspecified