Provider Demographics
NPI:1215962873
Name:ANTILLON-GALDAMEZ, MAINOR R (MD)
Entity type:Individual
Prefix:
First Name:MAINOR
Middle Name:R
Last Name:ANTILLON-GALDAMEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MAINOR
Other - Middle Name:R
Other - Last Name:ANTILLON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1510
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54702-1510
Mailing Address - Country:US
Mailing Address - Phone:715-838-5222
Mailing Address - Fax:
Practice Address - Street 1:1400 BELLINGER ST
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54703
Practice Address - Country:US
Practice Address - Phone:715-838-5222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301106568207RG0100X
WI67158207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO958385236Medicare PIN
MO752749OtherHEALTHLINK
MOE73580Medicare UPIN
MOP00360398Medicare PIN
MS01484317Medicaid
MOP00445137Medicare PIN
LA1798118Medicaid
LA4M6527061Medicare PIN
MO958381879Medicare PIN
MO201322906Medicaid
LA4M6526629Medicare PIN