Provider Demographics
NPI:1194741710
Name:BANTOM, WALTER E III (MD)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:E
Last Name:BANTOM
Suffix:III
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 1:5615 W GIRARD AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-4128
Mailing Address - Country:US
Mailing Address - Phone:215-477-5800
Mailing Address - Fax:215-879-8447
Practice Address - Street 1:5615 W GIRARD AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-4128
Practice Address - Country:US
Practice Address - Phone:215-477-5800
Practice Address - Fax:215-879-8447
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD04394E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA218045OtherMEDICARE ID - TYPE UNSPECIFIED
PA1172977Medicaid
PA0110990001OtherINDEPENDENCE BLUE CROSS
PA1172977Medicaid