Provider Demographics
NPI:1710307087
Name:OLEG ANTONOV MD PC
Entity Type:Organization
Organization Name:OLEG ANTONOV MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OLEG
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTONOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:267-639-0528
Mailing Address - Street 1:11400 BUSTLETON AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19116-2815
Mailing Address - Country:US
Mailing Address - Phone:267-639-0528
Mailing Address - Fax:215-969-4451
Practice Address - Street 1:11400 BUSTLETON AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19116-2815
Practice Address - Country:US
Practice Address - Phone:267-639-0528
Practice Address - Fax:215-969-4451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-24
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD432473207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty