Provider Demographics
NPI:1285740530
Name:BANIEWICZ, JOHN J (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:BANIEWICZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:36000 EUCLID AVE
Mailing Address - Street 2:MSO
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094
Mailing Address - Country:US
Mailing Address - Phone:440-953-6082
Mailing Address - Fax:440-953-6101
Practice Address - Street 1:9485 MENTOR AVE
Practice Address - Street 2:STE 210
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060
Practice Address - Country:US
Practice Address - Phone:440-205-5835
Practice Address - Fax:440-205-5735
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35-058500207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0854160Medicaid
F12427Medicare UPIN
OH0854160Medicaid