Provider Demographics
NPI:1134337975
Name:ANTONIO, ADELAIDA B (MD)
Entity type:Individual
Prefix:DR
First Name:ADELAIDA
Middle Name:B
Last Name:ANTONIO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21001 SHERMAN WAY
Mailing Address - Street 2:SUITE 15
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91303-1760
Mailing Address - Country:US
Mailing Address - Phone:818-716-0048
Mailing Address - Fax:818-785-3330
Practice Address - Street 1:21001 SHERMAN WAY
Practice Address - Street 2:SUITE 15
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91303-1760
Practice Address - Country:US
Practice Address - Phone:818-716-0048
Practice Address - Fax:818-785-3330
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2011-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC41801207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C418010Medicaid
CAC41801Medicare ID - Type Unspecified