Provider Demographics
NPI:1437119708
Name:ANTALIK, THOMAS JOHN (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:JOHN
Last Name:ANTALIK
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 3193
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27715-3193
Mailing Address - Country:US
Mailing Address - Phone:919-544-6318
Mailing Address - Fax:919-544-6336
Practice Address - Street 1:511 RIDGE RD
Practice Address - Street 2:
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27573-4627
Practice Address - Country:US
Practice Address - Phone:336-597-5462
Practice Address - Fax:336-597-9428
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC37999208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8912194Medicaid
2141738Medicare ID - Type Unspecified
NC8912194Medicaid