Healthcare Provider Details

I. General information

NPI: 1760429476
Provider Name (Legal Business Name): MICHAEL SEAN ANTONIS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 04/13/2023
Certification Date: 04/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20041 RIVERSIDE COMMONS PLAZA
ASHBURN VA
20147
US

IV. Provider business mailing address

P. O. BOX 715868
PHILADELPHIA PA
19171-5868
US

V. Phone/Fax

Practice location:
  • Phone: 703-466-0447
  • Fax: 703-810-5313
Mailing address:
  • Phone: 804-215-3063
  • Fax: 804-968-1803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberDO034203
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number0102204828
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: