Provider Demographics
NPI:1376926972
Name:ANTOSIEK, KYLE EDWARD (DO)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:EDWARD
Last Name:ANTOSIEK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5680 BOW POINTE DR STE 102
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-5407
Mailing Address - Country:US
Mailing Address - Phone:248-221-1845
Mailing Address - Fax:833-645-2176
Practice Address - Street 1:5680 BOW POINTE DR STE 102
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-5407
Practice Address - Country:US
Practice Address - Phone:248-221-1845
Practice Address - Fax:833-645-2176
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-01
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101022121207RG0100X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty