Provider Demographics
NPI:1437187960
Name:ANTONIADES, JOHN T (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:T
Last Name:ANTONIADES
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 1:3449 WILKENS AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-5218
Mailing Address - Country:US
Mailing Address - Phone:667-234-9992
Mailing Address - Fax:667-234-9997
Practice Address - Street 1:3449 WILKENS AVE STE 300
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229
Practice Address - Country:US
Practice Address - Phone:667-234-9992
Practice Address - Fax:667-234-9997
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0058226207XS0114X, 207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD405613200Medicaid
MD405613200Medicaid
MD873AAN / 641767-01OtherBC / BS OF MD
MD405613200Medicaid
MD6379210001Medicare NSC
920M / J120Medicare ID - Type Unspecified