Provider Demographics
NPI:1801024732
Name:ANTOS, KYLE J (OD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:J
Last Name:ANTOS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 J ST
Mailing Address - Street 2:
Mailing Address - City:LAPORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-4734
Mailing Address - Country:US
Mailing Address - Phone:219-362-8923
Mailing Address - Fax:219-324-8183
Practice Address - Street 1:301 J ST
Practice Address - Street 2:
Practice Address - City:LAPORTE
Practice Address - State:IN
Practice Address - Zip Code:46350
Practice Address - Country:US
Practice Address - Phone:219-362-8923
Practice Address - Fax:219-324-8183
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003609A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200953020Medicaid
IN200953020Medicaid
IN236940CMedicare PIN
IN669220008Medicare PIN
IN236930CMedicare PIN
IN237280CMedicare PIN
IN452570011Medicare PIN