Provider Demographics
NPI:1326217563
Name:RONALD L BANTA, DPM, INC
Entity Type:Organization
Organization Name:RONALD L BANTA, DPM, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:BANTA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:317-843-2613
Mailing Address - Street 1:3077 E 98TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46280-2940
Mailing Address - Country:US
Mailing Address - Phone:317-843-2613
Mailing Address - Fax:317-574-5185
Practice Address - Street 1:3077 E 98TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46280-2940
Practice Address - Country:US
Practice Address - Phone:317-843-2613
Practice Address - Fax:317-574-5185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0175110001Medicare NSC