Provider Demographics
NPI:1780709592
Name:JOHN J. ANTALIS, MD INC
Entity type:Organization
Organization Name:JOHN J. ANTALIS, MD INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:ANTALIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:740-439-3020
Mailing Address - Street 1:1502 DEERPATH DR
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:43725-9240
Mailing Address - Country:US
Mailing Address - Phone:740-439-3020
Mailing Address - Fax:740-432-5487
Practice Address - Street 1:1502 DEERPATH DR
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:43725-9240
Practice Address - Country:US
Practice Address - Phone:740-439-3020
Practice Address - Fax:740-432-5487
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JOHN J. ANTALIS, MD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-20
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35060862207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHDG0782OtherRRB/ MEDICARE GROUP
OH180036464OtherRAILROAD MEDICARE
OH0916003Medicaid
OH9275952Medicare PIN
OH0916003Medicaid
OH0916003Medicaid