Provider Demographics
NPI:1295746584
Name:ANTOSH, MARK (MD)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:ANTOSH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:824 FRANKLIN PARK DR
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-1614
Mailing Address - Country:US
Mailing Address - Phone:315-432-1048
Mailing Address - Fax:315-432-9219
Practice Address - Street 1:824 FRANKLIN PARK DR
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-1614
Practice Address - Country:US
Practice Address - Phone:315-432-1048
Practice Address - Fax:315-432-9219
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1835571173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01420837Medicaid
NYF57621Medicare UPIN
NYBB1970Medicare ID - Type Unspecified