Provider Demographics
NPI:1629064191
Name:MANTIN, ARIE (MD)
Entity Type:Individual
Prefix:
First Name:ARIE
Middle Name:
Last Name:MANTIN
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 1:2245 LEWISVILLE CLEMMONS RD
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-7461
Mailing Address - Country:US
Mailing Address - Phone:336-712-8225
Mailing Address - Fax:336-712-8227
Practice Address - Street 1:2245 LEWISVILLE CLEMMONS RD
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-7461
Practice Address - Country:US
Practice Address - Phone:336-712-8225
Practice Address - Fax:336-712-8227
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-21
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2000-00535207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89136M4Medicaid
G21398Medicare UPIN
2288835CMedicare ID - Type Unspecified