Basic Information
| Provider Information | |||||||||
| NPI: | 1710050034 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MICHELL | ||||||||
| FirstName: | ANTONIO | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 E JEFFERSON ST | ||||||||
| Address2: | KAISER PERMANENTE MEDICARE ENROLLMENT | ||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208524908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018162424 | ||||||||
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| Practice Location | |||||||||
| Address1: | 201 N WASHINGTON ST FL 3 | ||||||||
| Address2: | KAISER PERMANENTE FALLS CHURCH MEDICAL CENTER | ||||||||
| City: | FALLS CHURCH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220464518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032374000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 12/06/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 0101042792 | VA | Y | Allopathic & Osteopathic Physicians | Urology | 208800000X | MD13322 | DC | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | D0036953 | MD | N | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 34698 | 05 | VA | MEDICAID |