Provider Demographics
NPI:1154307775
Name:ANTKOWIAK, GREGORY T (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:T
Last Name:ANTKOWIAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2810 CAMINO DEL RIO S
Mailing Address - Street 2:STE 102
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3818
Mailing Address - Country:US
Mailing Address - Phone:619-299-1419
Mailing Address - Fax:858-461-6008
Practice Address - Street 1:2810 CAMINO DEL RIO S
Practice Address - Street 2:STE 102
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3818
Practice Address - Country:US
Practice Address - Phone:619-299-1419
Practice Address - Fax:858-461-6008
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2014-12-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA78990207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA78990DMedicare PIN
CAI00826Medicare UPIN