Provider Demographics
NPI:1902800774
Name:RANTA, JEFFREY A (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:A
Last Name:RANTA
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 1:2600 MAIN ST
Mailing Address - Street 2:STE 119
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-5305
Mailing Address - Country:US
Mailing Address - Phone:570-724-3636
Mailing Address - Fax:570-724-3326
Practice Address - Street 1:15 MEADE ST STE U3
Practice Address - Street 2:
Practice Address - City:WELLSBORO
Practice Address - State:PA
Practice Address - Zip Code:16901
Practice Address - Country:US
Practice Address - Phone:570-724-3636
Practice Address - Fax:570-724-3326
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT025617208800000X
PAMD464517208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
020035OtherHEALTHNET
CT001256171Medicaid
340004055OtherRAILROAD MEDICARE
010025617CT01OtherBC/BS
025617OtherCONNETICARE
567460OtherAETNA
ZS719OtherOXFORD
CT001256171Medicaid
567460OtherAETNA
010025617CT01OtherBC/BS