Provider Demographics
NPI:1962447532
Name:BANTLE, JOHN A (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:A
Last Name:BANTLE
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 1:10519 BRIGHTSTONE DR
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-1570
Mailing Address - Country:US
Mailing Address - Phone:816-807-8333
Mailing Address - Fax:
Practice Address - Street 1:10519 BRIGHTSTONE DR
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-1570
Practice Address - Country:US
Practice Address - Phone:816-807-8333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101240013207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010314453Medicaid
VA204990OtherBLUE SHIELD
VA010290881Medicaid
VA010291020Medicaid
VA1962447532Medicaid
VAMC11753Medicare PIN
VA011575V20Medicare PIN
VA011360V21Medicare PIN
VA010291020Medicaid
VA010290881Medicaid
VA018432V68Medicare PIN
VA010314453Medicaid