Provider Demographics
NPI:1417006883
Name:BANITT, MICHAEL R (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:BANITT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:
Other - Last Name:BANITT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 102339
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91189-2339
Mailing Address - Country:US
Mailing Address - Phone:206-528-6000
Mailing Address - Fax:206-858-7050
Practice Address - Street 1:16404 SMOKEY POINT BLVD STE 303
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98223-8417
Practice Address - Country:US
Practice Address - Phone:360-658-6224
Practice Address - Fax:360-658-6227
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60583808207W00000X
MI4301089639207W00000X
FLME101497207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1417006883Medicaid