Provider Demographics
NPI:1912285081
Name:ANTONATOS, MIGUEL R (MD)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:R
Last Name:ANTONATOS
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 1:4803 N MILWAUKEE AVE
Mailing Address - Street 2:SUITE B UNIT #220
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630
Mailing Address - Country:US
Mailing Address - Phone:973-847-2280
Mailing Address - Fax:
Practice Address - Street 1:4803 N MILWAUKEE AVE
Practice Address - Street 2:SUITE B UNIT #220
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630
Practice Address - Country:US
Practice Address - Phone:973-847-2280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-23
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036138839207Q00000X, 208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD12428OtherSD LICENSE
KYC0084OtherKY LICENSE
FLME147653OtherFL LICENSE
WV30482OtherWV LICENSE
WI412-320OtherWI LICENSE
AL41925OtherAL LICENSE
AZ61076OtherAZ LICENSE
CAC177591OtherCA LICENSE
MDD0090753OtherMD LICENSE
MIEMC0000064OtherMI LICENSE
MS28569OtherMS LICENSE
NE33242OtherNE LICENSE
IL036138839OtherILLIONOIS LICENSE
KS04-44257OtherKS LICENSE
NV20724OtherNV LICENSE
VT42.0015135OtherVT LICENSE
MN68586OtherMN LICENSE
GA85397OtherGA LICENSE
NJ25MA10452000OtherNJ LICENSE
IAMD-47241OtherIA LICENSE
WAMD61023368OtherWA LICENSE
UT12087673-1205OtherUT LICENSE
SC33998OtherSC LICENSE
OK37913OtherOK LICENSE
TN60557OtherTN LICENSE
VA101275982OtherVA LICENSE
ND17108OtherND LICENSE
NH21180OtherNH LICENSE
NY311447OtherNY LICENSE
COCDR.0000338OtherCO LICENSE
IDMC-0780OtherID LICENSE