Provider Demographics
NPI:1720321730
Name:DE BANATE, MARY ANN (MD)
Entity type:Individual
Prefix:
First Name:MARY ANN
Middle Name:
Last Name:DE BANATE
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 1:11 SOUTH RD STE 120
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-2483
Mailing Address - Country:US
Mailing Address - Phone:860-837-5758
Mailing Address - Fax:860-837-5235
Practice Address - Street 1:11 SOUTH RD STE 120
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-2483
Practice Address - Country:US
Practice Address - Phone:860-837-5758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-28
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILP04900208000000X
CT73338208000000X, 2080P0006X
MA268200208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics