Provider Demographics
NPI:1437123650
Name:MANTIA, JEFFREY STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:STEPHEN
Last Name:MANTIA
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 1:2845 44TH ST SW SUITE 200
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-1200
Mailing Address - Country:US
Mailing Address - Phone:616-538-2410
Mailing Address - Fax:616-538-1557
Practice Address - Street 1:2845 44TH ST SW SUITE 200
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-1200
Practice Address - Country:US
Practice Address - Phone:616-538-2410
Practice Address - Fax:616-538-1557
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301061595208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics