Provider Demographics
NPI:1982893103
Name:ANTONCHAK, MARC A (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:A
Last Name:ANTONCHAK
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 1:1211 DUBLIN RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-1026
Mailing Address - Country:US
Mailing Address - Phone:614-486-5200
Mailing Address - Fax:614-486-9665
Practice Address - Street 1:1211 DUBLIN RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-1091
Practice Address - Country:US
Practice Address - Phone:614-486-5200
Practice Address - Fax:614-486-9665
Is Sole Proprietor?:No
Enumeration Date:2007-10-24
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35089230207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPO0762429OtherRAILROAD MEDICARE
OH2954156Medicaid
31-1425166OtherFEDERAL TAX ID
OH9279991OtherGROUP MEDICARE
OH4268911Medicare PIN