Basic Information
| Provider Information | |||||||||
| NPI: | 1255585865 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANTONY | ||||||||
| FirstName: | ANTONY | ||||||||
| MiddleName: | KALLUR | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KALLUR | ||||||||
| OtherFirstName: | ANTONY | ||||||||
| OtherMiddleName: | ANTONY | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2100 LOUISIANA BLVD NE STE 410 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871105412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057244300 | ||||||||
| FaxNumber: | 5057244384 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 LOUISIANA BLVD NE STE 410 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871105412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057244300 | ||||||||
| FaxNumber: | 5057344384 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2008 | ||||||||
| LastUpdateDate: | 09/30/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XP3100X | MD2010-0612 | NM | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Pediatric Orthopaedic Surgery | 207XS0117X | P67172 | NY | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | 207X00000X | MD2010-0612 | NM | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.