Provider Demographics
NPI:1912963679
Name:ANTOINE, JILL A (MD)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:A
Last Name:ANTOINE
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:PO BOX 1705
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-0132
Mailing Address - Country:US
Mailing Address - Phone:541-773-7273
Mailing Address - Fax:541-773-2027
Practice Address - Street 1:1093 ROYAL CT
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6130
Practice Address - Country:US
Practice Address - Phone:541-773-7273
Practice Address - Fax:541-773-2027
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG85473207L00000X
MA218621207L00000X
ORMD192745207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAT005CMedicare PIN
CAAT005BMedicare PIN
CAAY244Medicare PIN
COD43537Medicare UPIN
CAAT005AMedicare PIN
CADO886AMedicare PIN
CAAT005Medicare PIN
CAAT005DMedicare PIN