Provider Demographics
NPI:1578735999
Name:BANTUM, BRIAN MICHEAL (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:MICHEAL
Last Name:BANTUM
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 1:1055 ROBERTA LN
Mailing Address - Street 2:#103
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89431-2809
Mailing Address - Country:US
Mailing Address - Phone:775-331-2600
Mailing Address - Fax:775-331-2605
Practice Address - Street 1:1055 ROBERTA LN
Practice Address - Street 2:#103
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89431-2809
Practice Address - Country:US
Practice Address - Phone:775-331-2600
Practice Address - Fax:775-331-2605
Is Sole Proprietor?:No
Enumeration Date:2008-03-25
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPAPERWORK IN PROCESS390200000X
NV14341208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVGI791ZMedicare PIN