Provider Demographics
NPI:1568479137
Name:ANTOLIK, EVAN PAUL (DC)
Entity type:Individual
Prefix:DR
First Name:EVAN
Middle Name:PAUL
Last Name:ANTOLIK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3135 7TH ST
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-5970
Mailing Address - Country:US
Mailing Address - Phone:309-762-1431
Mailing Address - Fax:309-762-2680
Practice Address - Street 1:3135 7TH ST
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-5970
Practice Address - Country:US
Practice Address - Phone:309-762-1431
Practice Address - Fax:309-762-2680
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-008542111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL205755Medicare ID - Type Unspecified
ILU95245Medicare UPIN