Provider Demographics
NPI:1710033758
Name:MARK ANTOS, M.D.
Entity Type:Organization
Organization Name:MARK ANTOS, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:302-629-4255
Mailing Address - Street 1:1501 MIDDLEFORD RD
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19973-3615
Mailing Address - Country:US
Mailing Address - Phone:302-629-4255
Mailing Address - Fax:302-629-5777
Practice Address - Street 1:1501 MIDDLEFORD RD
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:DE
Practice Address - Zip Code:19973-3615
Practice Address - Country:US
Practice Address - Phone:302-629-4255
Practice Address - Fax:302-629-5777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE=========OtherFEDERAL TAX ID
DEE21837Medicare UPIN
DE469630Medicare ID - Type Unspecified