Provider Demographics
NPI:1124083274
Name:ANTAKI & ASSOCIATES INFECTIOUS DISEASE MEDICAL GROUP INC
Entity type:Organization
Organization Name:ANTAKI & ASSOCIATES INFECTIOUS DISEASE MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEAN-PEIRRE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTAKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-242-5299
Mailing Address - Street 1:801 S CHEVY CHASE DR
Mailing Address - Street 2:101
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-4431
Mailing Address - Country:US
Mailing Address - Phone:818-242-5299
Mailing Address - Fax:818-637-7607
Practice Address - Street 1:801 S CHEVY CHASE DR
Practice Address - Street 2:101
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-4431
Practice Address - Country:US
Practice Address - Phone:818-242-5299
Practice Address - Fax:818-637-7607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGROO93960Medicaid
CAGROO93960Medicaid
CA=========OtherTAX IDENTIFICATION NUMBER