Provider Demographics
NPI:1588779110
Name:BANIK, PRABIR (MD)
Entity type:Individual
Prefix:DR
First Name:PRABIR
Middle Name:
Last Name:BANIK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 S MARION AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-5808
Mailing Address - Country:US
Mailing Address - Phone:386-755-3016
Mailing Address - Fax:386-758-6005
Practice Address - Street 1:619 S MARION AVE
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-5808
Practice Address - Country:US
Practice Address - Phone:386-755-3016
Practice Address - Fax:386-758-6005
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY244087207R00000X, 207RG0300X
FLME 110031207RG0300X
FLME110031207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02618688Medicaid
FL59-3209933Medicaid
FLK0329Medicare PIN
NY0483S1Medicare PIN