Provider Demographics
NPI:1538142252
Name:KARDOUS, ANTIOAN (MD)
Entity Type:Individual
Prefix:
First Name:ANTIOAN
Middle Name:
Last Name:KARDOUS
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 1:1145 RESERVOIR AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-6055
Mailing Address - Country:US
Mailing Address - Phone:401-946-5001
Mailing Address - Fax:401-946-5101
Practice Address - Street 1:1145 RESERVOIR AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-6055
Practice Address - Country:US
Practice Address - Phone:401-946-5001
Practice Address - Fax:401-946-5101
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI10089207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
2847513OtherAETNA
RI272209OtherBLUE CROSS BLUE SHIELD
RI408195OtherBLUE CHIP
RIAK35758Medicaid
P00083165OtherRAILROAD MEDICARE
RIAK35758Medicaid