Provider Demographics
NPI:1649218785
Name:BANTA, RONALD L (DPM)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:L
Last Name:BANTA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:STE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3077 E 98TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46280-2940
Practice Address - Country:US
Practice Address - Phone:317-843-2613
Practice Address - Fax:317-574-5185
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000296A213ES0000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01424283OtherRAIL ROAD PTAN
IN100461080Medicaid
INT84750Medicare UPIN
IN0175110001Medicare NSC
INM400060086Medicare PIN
IN100461080Medicaid
IN266180420Medicare PIN