Basic Information
| Provider Information | |||||||||
| NPI: | 1508840158 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANTELL | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | GORDON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7951 E MAPLEWOOD AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | GREENWOOD VILLAGE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801114723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039307800 | ||||||||
| FaxNumber: | 3039307860 | ||||||||
| Practice Location | |||||||||
| Address1: | 4715 ARAPAHOE AVE | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803031385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033852000 | ||||||||
| FaxNumber: | 3034441839 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2005 | ||||||||
| LastUpdateDate: | 08/22/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 37539 | CO | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 99554771 | 05 | CO | MEDICAID |