Provider Demographics
NPI:1417910001
Name:ANTOKAL, DAVID I (CRNA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:I
Last Name:ANTOKAL
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 AMBULANCE DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3857
Mailing Address - Country:US
Mailing Address - Phone:770-836-9666
Mailing Address - Fax:770-836-9212
Practice Address - Street 1:601 DALLAS HWY
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-1202
Practice Address - Country:US
Practice Address - Phone:770-456-3000
Practice Address - Fax:770-456-3460
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN129608367500000X
FLAPRN11000385367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA464995055AMedicaid
GA464995055AMedicaid
GA43BBBQTMedicare ID - Type Unspecified