Provider Demographics
NPI:1205848512
Name:BANTA II, CHARLES JACK (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:JACK
Last Name:BANTA II
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 1:8220 WALNUT HILL LN STE 608
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4424
Mailing Address - Country:US
Mailing Address - Phone:214-987-3434
Mailing Address - Fax:214-987-3799
Practice Address - Street 1:8220 WALNUT HILL LN STE 608
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4424
Practice Address - Country:US
Practice Address - Phone:214-987-3434
Practice Address - Fax:214-987-3799
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0438207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX81W560OtherBLUE CROSS
TXE95106Medicare UPIN