Provider Demographics
NPI:1689634107
Name:BANTLE, CHARLES D (DO)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:D
Last Name:BANTLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1510
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54702-1510
Mailing Address - Country:US
Mailing Address - Phone:715-838-5552
Mailing Address - Fax:
Practice Address - Street 1:700 BUFFALO ST
Practice Address - Street 2:
Practice Address - City:MONDOVI
Practice Address - State:WI
Practice Address - Zip Code:54755-1371
Practice Address - Country:US
Practice Address - Phone:715-838-5222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29955207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30059200Medicaid
WI0505 20195Medicare ID - Type Unspecified
WI30059200Medicaid