Provider Demographics
NPI:1336249804
Name:ANTONOV, BORISLAV S (MD)
Entity Type:Individual
Prefix:
First Name:BORISLAV
Middle Name:S
Last Name:ANTONOV
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 1:400 SAVANNAH RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:LEWES
Mailing Address - State:DE
Mailing Address - Zip Code:19958-1499
Mailing Address - Country:US
Mailing Address - Phone:302-645-3555
Mailing Address - Fax:302-644-3560
Practice Address - Street 1:424 SAVANNAH RD
Practice Address - Street 2:
Practice Address - City:LEWES
Practice Address - State:DE
Practice Address - Zip Code:19958-1462
Practice Address - Country:US
Practice Address - Phone:302-645-3555
Practice Address - Fax:302-644-3560
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEDSL #C1-0006494207R00000X
DEC1-0006494208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE000000208393OtherUNISON HEALTH CARE-MCAID
DEP00382719OtherRAILROAD MEDICARE
DE522011HOSOtherBCBS OF DELAWARE-HOSPITAL
DE1336249804OtherDIAMOND STATE MEDICAID
DE1336249804Medicaid
DE1336249804OtherDE PHYSICIAN CARE-MCAID
DE591343OtherCOVENTRY HEALTH CARE
DE522011HOSOtherBCBS OF DELAWARE-HOSPITAL
DE020936B86Medicare PIN