Healthcare Provider Details

I. General information

NPI: 1033296942
Provider Name (Legal Business Name): ANTONIUS SUSATYO HADI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 12/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8401 MARKET ST
BOARDMAN OH
44512-6725
US

IV. Provider business mailing address

8401 MARKET ST
BOARDMAN OH
44512-6725
US

V. Phone/Fax

Practice location:
  • Phone: 330-729-4350
  • Fax: 330-729-4351
Mailing address:
  • Phone: 330-729-4350
  • Fax: 330-729-4351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number35046065
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: