Provider Demographics
NPI:1972713816
Name:EWA ANTONCZYK MD LLC
Entity type:Organization
Organization Name:EWA ANTONCZYK MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:KATRINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:FERRALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-647-8366
Mailing Address - Street 1:3850 FOOTHILLS RD
Mailing Address - Street 2:STE. 9
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4632
Mailing Address - Country:US
Mailing Address - Phone:575-382-3700
Mailing Address - Fax:575-382-3701
Practice Address - Street 1:3850 FOOTHILLS RD
Practice Address - Street 2:STE. 9
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4632
Practice Address - Country:US
Practice Address - Phone:575-382-3700
Practice Address - Fax:575-382-3701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2005-0482207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM64355381Medicaid
NM64355381Medicaid