Provider Demographics
NPI:1255404026
Name:ANTKOWIAK, LYNDSAY J (OD)
Entity type:Individual
Prefix:
First Name:LYNDSAY
Middle Name:J
Last Name:ANTKOWIAK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:LYNDSAY
Other - Middle Name:J
Other - Last Name:HUNTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:5345 SUNRISE BLVD
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-3539
Mailing Address - Country:US
Mailing Address - Phone:916-966-4716
Mailing Address - Fax:
Practice Address - Street 1:5345 SUNRISE BLVD
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-3539
Practice Address - Country:US
Practice Address - Phone:916-966-4716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV006913152W00000X
CA13234152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV07053Medicare UPIN
NYRA8367Medicare ID - Type Unspecified