Provider Demographics
NPI:1588740138
Name:BANTA, MICHELLE M (MD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:M
Last Name:BANTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4060 FOURTH AVE
Mailing Address - Street 2:SUITE 330
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2116
Mailing Address - Country:US
Mailing Address - Phone:619-291-2274
Mailing Address - Fax:619-291-2274
Practice Address - Street 1:4060 FOURTH AVE
Practice Address - Street 2:SUITE 330
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2116
Practice Address - Country:US
Practice Address - Phone:619-291-2274
Practice Address - Fax:619-291-2274
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG487512084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG48751Medicare ID - Type Unspecified
CAA92846Medicare UPIN