Provider Demographics
NPI:1417906801
Name:BANTLE, ROXANA GABRIELLA (MD)
Entity Type:Individual
Prefix:
First Name:ROXANA
Middle Name:GABRIELLA
Last Name:BANTLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10519 BRIGHTSTONE DR
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-1570
Mailing Address - Country:US
Mailing Address - Phone:804-378-4420
Mailing Address - Fax:804-378-4440
Practice Address - Street 1:13700 ST FRANCIS BLVD
Practice Address - Street 2:STE 501
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23114-3222
Practice Address - Country:US
Practice Address - Phone:804-378-4420
Practice Address - Fax:804-378-4440
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101240121208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010294568Medicaid
I38821Medicare UPIN