Provider Demographics
NPI:1548004146
Name:HALL, ANTONIO DEMETRIOUS
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:DEMETRIOUS
Last Name:HALL
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 1:2412 HOLT AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43219-1451
Mailing Address - Country:US
Mailing Address - Phone:614-623-8489
Mailing Address - Fax:
Practice Address - Street 1:10400 BLACKLICK EASTERN RD
Practice Address - Street 2:
Practice Address - City:PICKERINGTON
Practice Address - State:OH
Practice Address - Zip Code:43147-8235
Practice Address - Country:US
Practice Address - Phone:614-726-7359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-19
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator