Provider Demographics
NPI:1255323309
Name:VANTIL, ETHAN S (M D)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:S
Last Name:VANTIL
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3537 W FRONT ST
Mailing Address - Street 2:SUITE I
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7943
Mailing Address - Country:US
Mailing Address - Phone:231-935-8950
Mailing Address - Fax:231-935-8868
Practice Address - Street 1:3537 W FRONT ST
Practice Address - Street 2:SUITE I
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7943
Practice Address - Country:US
Practice Address - Phone:231-935-8950
Practice Address - Fax:231-935-8868
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301076955207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4298892Medicaid
MI4298892Medicaid
H33376Medicare UPIN