Provider Demographics
NPI:1083629646
Name:MANTAS, MICHAIL A (MD)
Entity Type:Individual
Prefix:
First Name:MICHAIL
Middle Name:A
Last Name:MANTAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:A
Other - Last Name:MANTAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:7203 JOHN W CARPENTER FWY
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75247-5113
Mailing Address - Country:US
Mailing Address - Phone:214-637-3737
Mailing Address - Fax:214-637-7014
Practice Address - Street 1:7203 JOHN W CARPENTER FWY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75247-5113
Practice Address - Country:US
Practice Address - Phone:214-637-3737
Practice Address - Fax:214-637-7014
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF4240207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX611494Medicare ID - Type Unspecified
TXD49719Medicare UPIN