| Doctor Name: | DR. BRIAN MICHAEL BANTUM |
| NPI Number: | 1578735999 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | M.D. |
| License Number: | PAPERWORK IN PROCESS |
| Business Practice Address: | 1055 Roberta Ln #103 Sparks, NV - 894312809 |
| Business Phone Number: | 7753312600 |
| Business Fax Number: | 7753312605 |
| Mailing Address: | 1055 Roberta Ln, #103 SPARKS |
| State: | NV |
| Postal Code: | 894312809 |
| Phone Number: | 7753312600 |
| Fax Number: | 7753312605 |
| NPI Enumeration Date: | 03/25/2008 |
| NPI Last Update Date: | 02/20/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 390200000X |
| License Number: | PAPERWORK IN PROCESS |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | NV |
| Taxonomy Type: | Student, Health Care |
| Taxonomy Classification: | Student in an Organized Health Care Education/Training Program |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual who is enrolled in an organized health care education/training program leading to a degree, certification, registration, and/or licensure to provide health care. |