Provider Demographics
NPI:1548524838
Name:ANTONIO, PATRICK
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:ANTONIO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 COX RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9263
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:630 MANTUA PIKE
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096-3233
Practice Address - Country:US
Practice Address - Phone:856-812-2220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-02
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0080401207Q00000X
VA0116025196207Q00000X
NJ25MB10216800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD424570YWV2Medicare PIN
MD466421YVZMedicare PIN
MD466421ZDDBMedicare PIN