Provider Demographics
NPI:1124172598
Name:BANTZ, ERIC W (MD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:W
Last Name:BANTZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 OLD MARLTON PIKE STE 211
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-8772
Mailing Address - Country:US
Mailing Address - Phone:609-953-7500
Mailing Address - Fax:609-953-9085
Practice Address - Street 1:103 OLD MARLTON PIKE STE 211
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NJ
Practice Address - Zip Code:08055-8772
Practice Address - Country:US
Practice Address - Phone:609-953-7500
Practice Address - Fax:609-953-9085
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA48238207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0811426OtherCIGNA PROVIDER #
NJP381888OtherOXFORD PROVIDER ID
NJ147995OtherKEYSTONE INSURANCE ID
NJ5312302Medicaid
NJ010003124010Medicaid
NJ3373326OtherAETNA PROVIDER ID
NJ721570737OtherTAX ID#
NJ83386Medicaid
NJJ017341OtherTRICARE PRIME PROVIDER ID
NJ0350808000OtherAMERIHEALTH HMO PROVIDER
NJ60012703OtherHORIZON-MERCY
NJ721570737OtherTAX ID#
NJP381888OtherOXFORD PROVIDER ID