Provider Demographics
NPI:1184773319
Name:ANTONOVIC, SANDRA ANA (MD)
Entity type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:ANA
Last Name:ANTONOVIC
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 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12442 SW SCHOLLS FERRY RD
Practice Address - Street 2:SUITE 205
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-0804
Practice Address - Country:US
Practice Address - Phone:503-216-9140
Practice Address - Fax:503-216-9145
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23792208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR272420Medicaid
OR272420Medicaid
ORR176622Medicare PIN