Basic Information
Provider Information | |||||||||
NPI: | 1225128895 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ANTAKI | ||||||||
FirstName: | TAMIM | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ANTAKLI | ||||||||
OtherFirstName: | TAMIM | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3300 S FISKE BLVD | ||||||||
Address2: |   | ||||||||
City: | ROCKLEDGE | ||||||||
State: | FL | ||||||||
PostalCode: | 329554306 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3214343455 | ||||||||
FaxNumber: | 3219517408 | ||||||||
Practice Location | |||||||||
Address1: | 1350 HICKORY ST | ||||||||
Address2: | SUITE 102 | ||||||||
City: | MELBOURNE | ||||||||
State: | FL | ||||||||
PostalCode: | 329013224 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3214343455 | ||||||||
FaxNumber: | 3214343456 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/13/2006 | ||||||||
LastUpdateDate: | 05/01/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | ME128056 | FL | Y |   | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |   |
ID Information
ID | Type | State | Issuer | Description | 017282900 | 05 | FL |   | MEDICAID | IP030Z | 01 | FL | MEDICARE | OTHER |