Provider Demographics
NPI:1144221359
Name:BANTA, LINDA J (MD)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:J
Last Name:BANTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:JANE
Other - Last Name:DELOACH BANTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
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:SUITE 135
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
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3779207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CK2746OtherMEDICARE RR
TX81342XOtherBCBS OF TEXAS
TX81342XOtherBCBS OF TEXAS
TXF17020Medicare UPIN
TX8844B6Medicare PIN