Provider Demographics
NPI:1780209361
Name:ANTONY, MICHAEL JACOB (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JACOB
Last Name:ANTONY
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 1:1515 HOLCOMBE BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-4000
Mailing Address - Country:US
Mailing Address - Phone:877-632-6789
Mailing Address - Fax:
Practice Address - Street 1:1515 HOLCOMBE BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-4000
Practice Address - Country:US
Practice Address - Phone:877-632-6789
Practice Address - Fax:409-772-5462
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-10
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10070767207R00000X
TXBP20085302207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXBP10070767OtherPHYSICIAN IN TRAINING