Provider Demographics
NPI:1417929480
Name:ANTOS, JOHN M (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:ANTOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GUTHRIE SQ
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1625
Mailing Address - Country:US
Mailing Address - Phone:570-888-5858
Mailing Address - Fax:
Practice Address - Street 1:1 GUTHRIE SQ
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:PA
Practice Address - Zip Code:18840-1625
Practice Address - Country:US
Practice Address - Phone:570-888-5858
Practice Address - Fax:570-887-5775
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY139819-12085R0202X
PAMD024966E2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009161350001Medicaid
PA300125078OtherRR MEDICARE PIN
PACC9269OtherRR MEDICARE GROUP
NY00785204Medicaid
NYCC8362OtherRR MEDICARE GROUP
PAGU039853OtherMEDICARE GROUP
NYP00207601OtherRR MEDICARE PIN
PACC9269OtherRR MEDICARE GROUP
NY00785204Medicaid
PA0009161350001Medicaid