Provider Demographics
NPI:1215023064
Name:MANTZ, ERIC P (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:P
Last Name:MANTZ
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 1:600 MORRIS ST 103
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1409
Mailing Address - Country:US
Mailing Address - Phone:304-388-7040
Mailing Address - Fax:304-388-7041
Practice Address - Street 1:600 MORRIS ST
Practice Address - Street 2:SUITE 103
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1409
Practice Address - Country:US
Practice Address - Phone:304-388-7040
Practice Address - Fax:304-388-7041
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV09636208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVP01106930OtherRAILROAD MEDICARE
WV0127930000Medicaid
WVP01106930OtherRAILROAD MEDICARE
WVWV0419AMedicare PIN
WVMA0449485Medicare ID - Type Unspecified