Sandra K Antoniak, M.D.
Individual provider Active NPI Psychiatry Physician · Tucson, AZ
NPI 1891992285 · NPPES record last updated Dec 3, 2021
Key facts
- NPI
- 1891992285
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Psychiatry Physician 2084P0800X
- License
- 266006 (NY)
- Practice address
- 3500 N Sabino Canyon Rd Unit 54
Tucson, AZ 85750-6141 - Phone
- (402) 305-1921
- NPI assigned
- Jun 28, 2007
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 4
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in NY, AZ
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20150403000011 | NY | Practitioner - Psychiatry | 2769709641 | Reassigns benefits to 2 organizations |
| I20210514002221 | AZ | Practitioner - Psychiatry | 2769709641 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 266006 | NY | MD | Forensic Psychiatry Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Access: Supports for Living Inc | Current |
Accepting new patients | |
| Aleph Center, P.L.L.C. | Psychiatry | Current |
Accepting new patients |
| Champlain Valley Physicians Hospital Medical Center | Family Medicine | Current |
Accepting new patients |
| Access: Supports for Living Inc. | Current |
Accepting new patients |
Locations
6408 E Tanque Verde Rd
Tucson, AZ 85715
Phone (520) 885-5558
21 Grand St
Newburgh, NY 12550
Phone (845) 562-7244
67 Windsor Hwy
Newburgh, NY 12553
Phone (845) 562-6850
75 Beekman St
Plattsburgh, NY 12901
Phone (518) 562-7100
15 Fortune Rd W
Scotchtown, NY 10941
Phone (845) 673-7123
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Child & Adolescent Psychiatry Physician | 2084P0804X | 266006 | NY | |
| Psychiatry Physician | 2084P0800X | 266006 | NY | Yes |
| Forensic Psychiatry Physician | 2084F0202X | 266006 | NY |
Addresses
Primary practice location
3500 N Sabino Canyon Rd Unit 54
Tucson, AZ 85750-6141
Mailing address
3500 N Sabino Canyon Rd Unit 54
Tucson, AZ 85750-6141
Phone (402) 305-1921
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 266006 | Other | NY | LICENSE |
| 03615758 | Medicaid | NY |
Other providers in Tucson, AZ
- Luis Arturo Antillon Jr.
- Jessi Lin Antle-Williams
- Kyle Antle
- Rein Anton
- Jessica Antonel
- Jodi Fay Antrobus
- Nneka Feora Anuligo
- Brittany Anundson
- Elhaam Anvar
- Farah Anwar
All providers in Tucson, AZ · Psychiatry Physician in Arizona
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Dec 3, 2021. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.