Provider Demographics
NPI:1588836043
Name:ANTKOWIAK, MARYELLEN CLEARY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARYELLEN
Middle Name:CLEARY
Last Name:ANTKOWIAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 COLCHESTER AVE.
Mailing Address - Street 2:UVM MEDICAL CENTER - PULMONARY & CRITICAL CARE MEDICINE
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401
Mailing Address - Country:US
Mailing Address - Phone:802-847-1158
Mailing Address - Fax:802-847-2444
Practice Address - Street 1:111 COLCHESTER AVE.
Practice Address - Street 2:UVM MEDICAL CENTER - PULMONARY & CRITICAL CARE MEDICINE
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401
Practice Address - Country:US
Practice Address - Phone:802-847-1158
Practice Address - Fax:802-847-2444
Is Sole Proprietor?:No
Enumeration Date:2008-03-25
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0012284207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine