Healthcare Provider Details

I. General information

NPI: 1780909184
Provider Name (Legal Business Name): MATTHEW MICHAEL BANTI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2010
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040A JACKSON AVE
JBLM WA
98431
US

IV. Provider business mailing address

9040A JACKSON AVE
JBLM WA
98431
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-1111
  • Fax:
Mailing address:
  • Phone: 253-968-1541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number0443134
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number2020012676
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number26476
License Number StateNE
# 4
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMD-23249-0
License Number StateHI
# 5
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number01089852A
License Number StateIN
# 6
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number60664462
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: