Healthcare Provider Details

I. General information

NPI: 1437187960
Provider Name (Legal Business Name): JOHN T ANTONIADES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 05/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3449 WILKENS AVE STE 300
BALTIMORE MD
21229
US

IV. Provider business mailing address

3449 WILKENS AVE STE 300
BALTIMORE MD
21229-5218
US

V. Phone/Fax

Practice location:
  • Phone: 667-234-9992
  • Fax: 667-234-9997
Mailing address:
  • Phone: 667-234-9992
  • Fax: 667-234-9997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License NumberD0058226
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberD0058226
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberD0058226
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: