Provider Demographics
NPI:1073654422
Name:ANTOLICK, LARRY ALBERT (DO)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:ALBERT
Last Name:ANTOLICK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3527 SOMERSET CIR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34746-2874
Mailing Address - Country:US
Mailing Address - Phone:407-518-0420
Mailing Address - Fax:
Practice Address - Street 1:3527 SOMERSET CIR
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34746-2874
Practice Address - Country:US
Practice Address - Phone:407-518-0420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS003289L207QG0300X
FLOS8066207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA161541Medicare ID - Type Unspecified
PAD77399Medicare UPIN