Provider Demographics
NPI:1740324888
Name:ANTCZAK, MATTHEW TODD
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:TODD
Last Name:ANTCZAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:669 E CALHOUN ST
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-4262
Mailing Address - Country:US
Mailing Address - Phone:815-334-8334
Mailing Address - Fax:
Practice Address - Street 1:669 E CALHOUN ST
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-4262
Practice Address - Country:US
Practice Address - Phone:815-334-8334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-007424111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL05606277OtherBLUE CROSS BLUE SHIELD
ILU53852Medicare UPIN
IL359890Medicare ID - Type Unspecified