MEDICARE: NICHOLAS E. BANTZ OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	18004499A	IN

General Provider Information

NPI Number	:	1063254829
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS E. BANTZ OD

Provider Business Mailing Address
First Line	:	2887 S STATE ROAD 135
Second Line	:
City	:	GREENWOOD
State	:	IN
Zip	:	46143-9604
Country	:	US
Telephone Number	:	317-865-6829
Fax Number	:	317-886-7955

Provider Business Practice Location Address
First Line	:	13840 E 96TH ST
Second Line	:
City	:	MCCORDSVILLE
State	:	IN
Zip	:	46055-9394
Country	:	US
Telephone Number	:	317-720-2020
Fax Number	:	317-886-7955

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2024
Last Update Date	:	06/11/2024

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