Provider Demographics
NPI:1003842220
Name:ANETAKIS, ALEXANDER
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:ANETAKIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 NEW HANOVER MEDICAL PARK DRIVE
Mailing Address - Street 2:RETINA OF COASTAL CAROLINA
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-5351
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4600 OLEANDER DR
Practice Address - Street 2:RETINA OF COASTAL CAROLINA
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-5897
Practice Address - Country:US
Practice Address - Phone:910-254-2023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28771207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5903710Medicaid
SCQPA675Medicaid
SC287718Medicaid
P00326375OtherRAILROAD MEDICARE
SC562162061OtherSC BCBS
NC790129CMedicaid
ALI04828Medicare UPIN
SC287718Medicaid
NC5903710Medicaid