Provider Demographics
NPI:1033296942
Name:HADI, ANTONIUS SUSATYO (MD)
Entity Type:Individual
Prefix:
First Name:ANTONIUS
Middle Name:SUSATYO
Last Name:HADI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8401 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-6725
Mailing Address - Country:US
Mailing Address - Phone:330-729-4350
Mailing Address - Fax:330-729-4351
Practice Address - Street 1:8401 MARKET ST
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-6725
Practice Address - Country:US
Practice Address - Phone:330-729-4350
Practice Address - Fax:330-729-4351
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35046065207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH087621OtherMEDICARE PTAN
OH2444519Medicaid
OHH087621OtherMEDICARE PTAN
OH2444519Medicaid
E07234Medicare UPIN