Provider Demographics
NPI:1639850860
Name:ANTIC, ANDREA (OD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:
Last Name:ANTIC
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1588 FAR DR
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-1643
Mailing Address - Country:US
Mailing Address - Phone:901-230-5965
Mailing Address - Fax:
Practice Address - Street 1:5847 POPLAR AVE STE 105
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-3949
Practice Address - Country:US
Practice Address - Phone:901-498-6284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3835152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist