Provider Demographics
NPI:1699884890
Name:BANIKARIM, CHANTAY (MD)
Entity type:Individual
Prefix:
First Name:CHANTAY
Middle Name:
Last Name:BANIKARIM
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:FILE 56765
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-6765
Mailing Address - Country:US
Mailing Address - Phone:602-406-3860
Mailing Address - Fax:602-406-6132
Practice Address - Street 1:222 W THOMAS RD
Practice Address - Street 2:SUITE 301
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4419
Practice Address - Country:US
Practice Address - Phone:602-406-4772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ300802080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ761404Medicaid
AZZ146288Medicare PIN