Provider Demographics
NPI:1952867558
Name:ANTILLON, ANDREW M (DO)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:M
Last Name:ANTILLON
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 1:3700 ROSS AVE APT 123
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-5429
Mailing Address - Country:US
Mailing Address - Phone:214-771-6210
Mailing Address - Fax:
Practice Address - Street 1:327 BEACH 19TH ST
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-4423
Practice Address - Country:US
Practice Address - Phone:214-771-6210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-19
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXT7854207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program