Provider Demographics
NPI:1083607410
Name:SHANTZ, IAN M (MD)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:M
Last Name:SHANTZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12622
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4017
Mailing Address - Country:US
Mailing Address - Phone:443-481-6576
Mailing Address - Fax:443-481-6515
Practice Address - Street 1:2401 BRANDERMILL BLVD
Practice Address - Street 2:SUITE 250
Practice Address - City:GAMBRILLS
Practice Address - State:MD
Practice Address - Zip Code:21054-1690
Practice Address - Country:US
Practice Address - Phone:410-721-1507
Practice Address - Fax:410-721-1510
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2013-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0036203207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
4668884OtherAETNA PPO
9961OtherKAISER
0002OtherBCBS
2133458OtherMAMSI
MD278331200Medicaid
609636400OtherFEDERAL WORKMANS COMP
2110345OtherAETNA HMO
52030309OtherBCBS
218331200OtherAMERIGROUP
0002OtherBCBS
129N045GMedicare PIN
52030309OtherBCBS