Sandra Ana Antonovic, M.D.

Primary specialty

Pediatrics PhysicianTaxonomy code 208000000X

License

MD23792 Issued in OR

Practice address

12442 SW Scholls Ferry Rd
Suite 205
Tigard, OR 97223-0804

Phone

(503) 216-9140

Fax

(503) 216-9145

NPI assigned

Jan 9, 2007

Last updated

Oct 13, 2020By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in OR

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: santonovic101784@oc.providencedirect.org

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Providence Health & Services Oregon

  dba Providence Medical Group

  • General Practice Physician
  • Lake Oswego, OR
  • NPI 1023488343
  Medicare reassignment NPD
• Providence Health & Services - Oregon

  dba Providence Medical Group

  • Family Medicine Physician
  • Tigard, OR
  • NPI 1396836276
  NPD
• Providence Health & Services Oregon

  dba Providence Medical Group

  • Psychiatry Physician
  • Portland, OR
  • NPI 1760177737
  NPD
• Providence Health & Services - Oregon

  dba Providence Medical Group

  • Internal Medicine Physician
  • Sherwood, OR
  • NPI 1184729329

  Pediatrics

  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1168300800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1602547200000",
    "number": "1184773319",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 3158",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972083158"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12442 SW SCHOLLS FERRY RD",
            "address_2": "SUITE 205",
            "city": "TIGARD",
            "state": "OR",
            "postal_code": "972230804",
            "telephone_number": "503-216-9140",
            "fax_number": "503-216-9145"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ANTONOVIC",
        "first_name": "SANDRA",
        "middle_name": "ANA",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2007-01-09",
        "last_updated": "2020-10-13",
        "certification_date": "2020-10-13",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "OR",
            "license": "MD23792",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "272420",
            "state": "OR"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "santonovic101784@oc.providencedirect.org",
            "affiliation": "N",
            "address_1": "12442 SW SCHOLLS FERRY RD",
            "address_2": "SUITE 205",
            "city": "TIGARD",
            "state": "OR",
            "country_code": "US",
            "postal_code": "972230804",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

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• Pediatrics Physician in Tigard, OR
• Providers in Tigard, OR by specialty
• Pediatrics Physician in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 13, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.