Provider Demographics
NPI:1679082572
Name:ANTONIO, PHILLIP JOHN
Entity type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:JOHN
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 1:8792 HAZELTINE AVE
Mailing Address - Street 2:
Mailing Address - City:PANORAMA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91402-2552
Mailing Address - Country:US
Mailing Address - Phone:818-642-7785
Mailing Address - Fax:
Practice Address - Street 1:18111 NORDHOFF STREET, CALIFORNIA STATE NORTHRIDGE
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91330-8287
Practice Address - Country:US
Practice Address - Phone:818-642-7785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-22
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X, 2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program