Provider Demographics
NPI:1891740270
Name:ANTONCZYK, EWA (MD)
Entity type:Individual
Prefix:
First Name:EWA
Middle Name:
Last Name:ANTONCZYK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:647 DUNLOP LN
Mailing Address - Street 2:SUITE 108
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-5165
Mailing Address - Country:US
Mailing Address - Phone:931-502-3660
Mailing Address - Fax:
Practice Address - Street 1:647 DUNLOP LN
Practice Address - Street 2:SUITE 108
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-5165
Practice Address - Country:US
Practice Address - Phone:931-502-3660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2005-0482207R00000X
TN46834207R00000X
FLME93992207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I46151Medicare UPIN
NM343533602Medicare PIN