1710987904 NPI number — GUSTAVO MIGUEL BANTI M.D.

Table of content: GUSTAVO MIGUEL BANTI M.D. (NPI 1710987904)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710987904 NPI number — GUSTAVO MIGUEL BANTI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BANTI
Provider First Name:
GUSTAVO
Provider Middle Name:
MIGUEL
Provider Name Prefix Text:
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:
1710987904
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/25/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8600 NW 41ST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DORAL
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33166-6202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-642-5366
Provider Business Mailing Address Fax Number:
305-644-6407

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2020 W 64TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HIALEAH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33016-2607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-642-5366
Provider Business Practice Location Address Fax Number:
305-644-6407
Provider Enumeration Date:
07/28/2005

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: 208800000X , with the licence number:  ME112201 , 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: 776955 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4500628 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036063412 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01137572 . This is a "RAILROAD MCR" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 4016817 . This is a "AETNA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 328075 . This is a "UNIVERSAL HEALTHCARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 2136778 . This is a "CIGNA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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