Provider Demographics
NPI:1417927351
Name:ANTOLIK, JOHN JOSEPH (MD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:JOSEPH
Last Name:ANTOLIK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:J
Other - Last Name:ANTOLIK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:728 MOLALLA AVE
Mailing Address - Street 2:#C
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-2652
Mailing Address - Country:US
Mailing Address - Phone:503-557-1233
Mailing Address - Fax:503-557-1310
Practice Address - Street 1:728 MOLALLA AVE
Practice Address - Street 2:#C
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045
Practice Address - Country:US
Practice Address - Phone:503-557-1233
Practice Address - Fax:503-557-1310
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD14415208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR029165Medicaid
E79047Medicare UPIN
OR029165Medicaid