Provider Demographics
NPI:1528067972
Name:ANTONISKIS, ANDRIS (MD)
Entity type:Individual
Prefix:
First Name:ANDRIS
Middle Name:
Last Name:ANTONISKIS
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:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:5228 NE HOYT ST
Practice Address - Street 2:BLDG B, 3RD FLOOR
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-3055
Practice Address - Country:US
Practice Address - Phone:503-215-2584
Practice Address - Fax:503-215-1524
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD10115207R00000X, 207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR220376Medicaid
OR500626738Medicaid
C94249Medicare UPIN
OR500626738Medicaid