MEDICARE: EWA ANTONCZYK MD LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	2005-0482	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1972713816
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EWA ANTONCZYK MD LLC

Provider Business Mailing Address
First Line	:	3850 FOOTHILLS RD
Second Line	:	STE. 9
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-4632
Country	:	US
Telephone Number	:	575-382-3700
Fax Number	:	575-382-3701

Provider Business Practice Location Address
First Line	:	3850 FOOTHILLS RD
Second Line	:	STE. 9
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-4632
Country	:	US
Telephone Number	:	575-382-3700
Fax Number	:	575-382-3701

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	KATRINA M FERRALES
Credential	:
Telephone Number	:	575-647-8366

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	05/06/2008

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