Provider Demographics
NPI:1104123546
Name:BANZON, ELEANOR RESANE (MD)
Entity type:Individual
Prefix:DR
First Name:ELEANOR
Middle Name:RESANE
Last Name:BANZON
Suffix:
Gender:F
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:PO BOX 820
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-0820
Mailing Address - Country:US
Mailing Address - Phone:917-397-0555
Mailing Address - Fax:
Practice Address - Street 1:500 E 51ST ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-2400
Practice Address - Country:US
Practice Address - Phone:312-572-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-22
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.139820207RC0200X
DEC1-0010468207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1104123546Medicaid
DEP01257423OtherRAIL ROAD MEDICARE
MD5323029 00Medicaid
DEP01257423OtherRAIL ROAD MEDICARE