Provider Demographics
NPI:1306811237
Name:ANTILES, MICHELLE E (DO)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:E
Last Name:ANTILES
Suffix:
Gender:F
Credentials:DO
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 14890
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4890
Mailing Address - Country:US
Mailing Address - Phone:518-525-5634
Mailing Address - Fax:
Practice Address - Street 1:1270 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12308-2104
Practice Address - Country:US
Practice Address - Phone:518-382-4560
Practice Address - Fax:518-386-3619
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY19155455208100000X
NY1915542081H0002X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081H0002XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01788852Medicaid
NY01788852Medicaid
NY01788852Medicaid