1205896636 NPI number — DR. KEITH B BANTON M.D.

Table of content: DR. KEITH B BANTON M.D. (NPI 1205896636)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205896636 NPI number — DR. KEITH B BANTON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BANTON
Provider First Name:
KEITH
Provider Middle Name:
B
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205896636
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/22/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3230 E 15TH ST
Provider Second Line Business Mailing Address:
UNIT B
Provider Business Mailing Address City Name:
PANAMA CITY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32405-7423
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-763-4700
Provider Business Mailing Address Fax Number:
850-763-4999

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1937 HARRISON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PANAMA CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32405-4543
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-763-4700
Provider Business Practice Location Address Fax Number:
850-763-4999
Provider Enumeration Date:
03/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  ME0085024 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 265799600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 13636 . This is a "BCBS OF FLORIDA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 265799600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com