Provider Demographics
NPI:1730286485
Name:ANTONIADIS, ATHANASIOS (MD)
Entity Type:Individual
Prefix:
First Name:ATHANASIOS
Middle Name:
Last Name:ANTONIADIS
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 1:750 MONTAUK HWY
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-4411
Mailing Address - Country:US
Mailing Address - Phone:631-376-1010
Mailing Address - Fax:
Practice Address - Street 1:750 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4411
Practice Address - Country:US
Practice Address - Phone:631-376-1010
Practice Address - Fax:631-376-6156
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1831001207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP790338OtherOXFORD
NY37K392OtherBLUE CROSS
NYF25457Medicare UPIN
NY37K392OtherBLUE CROSS