Provider Demographics
NPI:1558486084
Name:BANTOLO, MICHAEL P (PT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:P
Last Name:BANTOLO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:200 NEWPORT CENTER DR
Mailing Address - Street 2:#213
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7501
Mailing Address - Country:US
Mailing Address - Phone:949-644-1322
Mailing Address - Fax:949-644-0316
Practice Address - Street 1:1400 S HARBOR BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:LA HABRA
Practice Address - State:CA
Practice Address - Zip Code:90631-7577
Practice Address - Country:US
Practice Address - Phone:714-441-0763
Practice Address - Fax:714-441-0883
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA26696225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAV270ZMedicare PIN
CAZZZ23993ZMedicare PIN