Healthcare Provider Details

I. General information

NPI: 1629064191
Provider Name (Legal Business Name): ARIE MANTIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 07/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2245 LEWISVILLE CLEMMONS RD
CLEMMONS NC
27012-7461
US

IV. Provider business mailing address

2245 LEWISVILLE CLEMMONS RD
CLEMMONS NC
27012-7461
US

V. Phone/Fax

Practice location:
  • Phone: 336-712-8225
  • Fax: 336-712-8227
Mailing address:
  • Phone: 336-712-8225
  • Fax: 336-712-8227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2000-00535
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: