Provider Demographics
NPI:1366558314
Name:D'ANTONIO, HENRY (OD)
Entity type:Individual
Prefix:
First Name:HENRY
Middle Name:
Last Name:D'ANTONIO
Suffix:
Gender:M
Credentials:OD
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 2993
Mailing Address - Street 2:
Mailing Address - City:LAKE ARROWHEAD
Mailing Address - State:CA
Mailing Address - Zip Code:92352-2993
Mailing Address - Country:US
Mailing Address - Phone:909-337-4310
Mailing Address - Fax:909-336-5937
Practice Address - Street 1:29099 HOSPITAL RD
Practice Address - Street 2:SUITE 205
Practice Address - City:LAKE ARROWHEAD
Practice Address - State:CA
Practice Address - Zip Code:92352-2993
Practice Address - Country:US
Practice Address - Phone:909-337-4310
Practice Address - Fax:909-336-5937
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40780152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT69829Medicare UPIN