Provider Demographics
NPI:1992754097
Name:D'ANTONIO, MICHAEL GERARD (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GERARD
Last Name:D'ANTONIO
Suffix:
Gender:M
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 1339
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70073-1339
Mailing Address - Country:US
Mailing Address - Phone:504-349-1461
Mailing Address - Fax:504-349-1461
Practice Address - Street 1:1111 MEDICAL CENTER BLVD
Practice Address - Street 2:STE. N-108
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3151
Practice Address - Country:US
Practice Address - Phone:504-349-1461
Practice Address - Fax:504-349-1461
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2011-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0205732085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05054550Medicaid
LA1681521Medicaid
LA5W937Medicare ID - Type Unspecified
F78049Medicare UPIN