Provider Demographics
NPI:1922665504
Name:MOTLEY, ANTONIO
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:MOTLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16221 MANSFIELD ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-3630
Mailing Address - Country:US
Mailing Address - Phone:313-475-0592
Mailing Address - Fax:
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2689
Practice Address - Country:US
Practice Address - Phone:313-916-7474
Practice Address - Fax:313-916-8470
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-20
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5094952085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty