Provider Demographics
NPI:1013231216
Name:LINDA J. BANTA, M.D., P.A.
Entity Type:Organization
Organization Name:LINDA J. BANTA, M.D., P.A.
Other - Org Name:STONE OAK DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:BANTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-494-0504
Mailing Address - Street 1:PO BOX 2493
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78299-2493
Mailing Address - Country:US
Mailing Address - Phone:210-494-0504
Mailing Address - Fax:210-494-0593
Practice Address - Street 1:109 GALLERY CIR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-3327
Practice Address - Country:US
Practice Address - Phone:210-494-0504
Practice Address - Fax:210-494-0593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-17
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3779207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0083TJOtherBCBS