Provider Demographics
NPI:1225128895
Name:ANTAKI, TAMIM (MD)
Entity Type:Individual
Prefix:
First Name:TAMIM
Middle Name:
Last Name:ANTAKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:TAMIM
Other - Middle Name:
Other - Last Name:ANTAKLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-434-3455
Mailing Address - Fax:321-951-7408
Practice Address - Street 1:1350 HICKORY ST
Practice Address - Street 2:SUITE 102
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3224
Practice Address - Country:US
Practice Address - Phone:321-434-3455
Practice Address - Fax:321-434-3456
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME128056208G00000X, 208G00000X
IN01066078A208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017282900Medicaid
FLIP030ZOtherMEDICARE