Provider Demographics
NPI:1912961012
Name:DANIEL S KANTZ PSC
Entity Type:Organization
Organization Name:DANIEL S KANTZ PSC
Other - Org Name:DANIEL S KANTZ LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DO OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:KANTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:812-256-7830
Mailing Address - Street 1:2100 MARKET ST
Mailing Address - Street 2:#106
Mailing Address - City:CHARLESTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47111
Mailing Address - Country:US
Mailing Address - Phone:812-256-7830
Mailing Address - Fax:812-256-7835
Practice Address - Street 1:2100 MARKET ST
Practice Address - Street 2:#106
Practice Address - City:CHARLESTOWN
Practice Address - State:IN
Practice Address - Zip Code:47111
Practice Address - Country:US
Practice Address - Phone:812-256-7830
Practice Address - Fax:812-256-7835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002542A208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64068968Medicaid
IN231350AMedicare ID - Type Unspecified
G86498Medicare UPIN