Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207QG0300X | Family Doctor - Geriatric Medicine | OS003289L | PA |
Y | 207QG0300X | Family Doctor - Geriatric Medicine | OS8066 | FL |
NPI | 1073654422 |
---|---|
Provider Name | Dr. Larry Albert Antolick |
First Address | Kissimmee, FL 34746-2874 |
Second Address | Kissimmee, FL 34746-2874 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/02/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
D77399 | (02) | PA |