Provider Demographics
NPI:1750374005
Name:ANTONIO, DAVID RICHARD (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:RICHARD
Last Name:ANTONIO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 BOULDERS PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23225-4067
Mailing Address - Country:US
Mailing Address - Phone:804-560-5595
Mailing Address - Fax:804-560-9029
Practice Address - Street 1:95 HARRIS RD
Practice Address - Street 2:BUILDING 5
Practice Address - City:KILMARNOCK
Practice Address - State:VA
Practice Address - Zip Code:22482-3845
Practice Address - Country:US
Practice Address - Phone:804-435-3146
Practice Address - Fax:804-435-6054
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101034363174400000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA011595OtherANTHEM HEALTH PLANS OF VA
VA1750374005Medicaid
VA200005729OtherRAILROAD MEDICARE
VA64-12785Medicaid
VAP00717232OtherRR MEDICARE
VA011595OtherANTHEM HEALTH PLANS OF VA
VA200000033Medicare PIN
VA0472640018Medicare NSC
VAMC12124Medicare PIN