Provider Demographics
NPI:1982991683
Name:ANTONIO, AILEEN ELIZABETH M AMPIL (MD)
Entity Type:Individual
Prefix:DR
First Name:AILEEN ELIZABETH M
Middle Name:AMPIL
Last Name:ANTONIO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:AILEEN
Other - Middle Name:
Other - Last Name:ANTONIO-SANTOS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1900 44TH ST SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-5008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:616-391-3130
Practice Address - Street 1:245 CHERRY ST SE
Practice Address - Street 2:SUITE 204
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4607
Practice Address - Country:US
Practice Address - Phone:616-685-5050
Practice Address - Fax:616-685-3050
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-01
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010979302084N0400X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology