Basic Information
| Provider Information | |||||||||
| NPI: | 1487683793 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANTONIOU | ||||||||
| FirstName: | NIKOLAS | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7900 ROLLINS RD STE 1100 | ||||||||
| Address2: | |||||||||
| City: | GURNEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600311512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473563680 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7900 ROLLINS RD STE 1100 | ||||||||
| Address2: | |||||||||
| City: | GURNEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600311512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473563680 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 03/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036-098315 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036-098315 | 01 | IL | STATE LICENSE | OTHER | 036-098315 | 05 | IL | MEDICAID |