Provider Demographics
NPI:1396186201
Name:OLEG ANTONOV MD PC
Entity Type:Organization
Organization Name:OLEG ANTONOV MD PC
Other - Org Name:11400 BUSTLETON AVENUE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:OLEG
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTONOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-111-1111
Mailing Address - Street 1:11400 BUSTLETON AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19116-2815
Mailing Address - Country:US
Mailing Address - Phone:215-111-1111
Mailing Address - Fax:
Practice Address - Street 1:11400 BUSTLETON AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19116
Practice Address - Country:US
Practice Address - Phone:215-111-1111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-09
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty