Provider Demographics
NPI:1922255611
Name:ANTANAVICIUS, KRISTINA (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTINA
Middle Name:
Last Name:ANTANAVICIUS
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:PO BOX 191
Mailing Address - Street 2:
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6212
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:1600 ROCKLAND RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-3607
Practice Address - Country:US
Practice Address - Phone:302-651-4200
Practice Address - Fax:302-651-5365
Is Sole Proprietor?:No
Enumeration Date:2008-08-25
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD432253207L00000X
DEC10010170207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1022649500001Medicaid
PA1022649500001Medicaid