Provider Demographics
NPI:1164486825
Name:NATHAN, ANNETTE RAQUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:ANNETTE
Middle Name:RAQUEL
Last Name:NATHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANNETTE
Other - Middle Name:
Other - Last Name:BECKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2699 KILKENNY CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-1164
Mailing Address - Country:US
Mailing Address - Phone:937-390-0971
Mailing Address - Fax:
Practice Address - Street 1:100 MEDICAL CENTER WAY
Practice Address - Street 2:SPRINGFIELD REGIONAL MEDICAL CENTER
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45505
Practice Address - Country:US
Practice Address - Phone:937-523-1401
Practice Address - Fax:937-523-1950
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-12
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.064717207P00000X
OH3564717207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000017028OtherANTHEM
OH0924914Medicaid
OH0924914Medicaid
OHF16363Medicare UPIN
OH000000017028OtherANTHEM
OHNA0743122Medicare PIN