Healthcare Provider Details

I. General information

NPI: 1992384887
Provider Name (Legal Business Name): KATRINA S. BANTIS DO, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2021
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3540 JOHN F KENNEDY BLVD STE 201&301
JERSEY CITY NJ
07307-3450
US

IV. Provider business mailing address

220 DAVIDSON AVE STE 124
SOMERSET NJ
08873-4123
US

V. Phone/Fax

Practice location:
  • Phone: 201-333-2221
  • Fax:
Mailing address:
  • Phone: 732-314-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number25MB13222600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: