Provider Demographics
NPI:1891992285
Name:ANTONIAK, SANDRA K (MD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:K
Last Name:ANTONIAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 N SABINO CANYON RD UNIT 54
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85750-6141
Mailing Address - Country:US
Mailing Address - Phone:402-305-1921
Mailing Address - Fax:
Practice Address - Street 1:3500 N SABINO CANYON RD UNIT 54
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85750-6141
Practice Address - Country:US
Practice Address - Phone:402-305-1921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2660062084P0804X, 2084P0800X, 2084F0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY266006OtherLICENSE
NY03615758Medicaid