Provider Demographics
NPI:1063254829
Name:BANTZ, NICHOLAS E (OD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:E
Last Name:BANTZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2887 S STATE ROAD 135
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-9604
Mailing Address - Country:US
Mailing Address - Phone:317-865-6829
Mailing Address - Fax:317-886-7955
Practice Address - Street 1:13840 E 96TH ST
Practice Address - Street 2:
Practice Address - City:MCCORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46055-9394
Practice Address - Country:US
Practice Address - Phone:317-720-2020
Practice Address - Fax:317-886-7955
Is Sole Proprietor?:No
Enumeration Date:2024-06-11
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004499A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist