Provider Demographics
NPI:1760642565
Name:ANTONOVA, VALENTINA MICHELLE (MD)
Entity type:Individual
Prefix:
First Name:VALENTINA
Middle Name:MICHELLE
Last Name:ANTONOVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VALENTYNA
Other - Middle Name:MIKHAYLOVNA
Other - Last Name:ANTONOVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:500 NE MULTNOMAH ST FL 11
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2023
Mailing Address - Country:US
Mailing Address - Phone:503-813-2000
Mailing Address - Fax:
Practice Address - Street 1:2875 NE STUCKI AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-5806
Practice Address - Country:US
Practice Address - Phone:503-813-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-15
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD169365207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03433185Medicaid
NYJ400066774/GRPBA0017Medicare PIN
NYJ400066775/GRP70008AMedicare PIN