Healthcare Provider Details

I. General information

NPI: 1124172598
Provider Name (Legal Business Name): ERIC W. BANTZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 07/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 OLD MARLTON PIKE STE 211
MEDFORD NJ
08055-8772
US

IV. Provider business mailing address

103 OLD MARLTON PIKE STE 211
MEDFORD NJ
08055-8772
US

V. Phone/Fax

Practice location:
  • Phone: 609-953-7500
  • Fax: 609-953-9085
Mailing address:
  • Phone: 609-953-7500
  • Fax: 609-953-9085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License NumberMA48238
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: