Provider Demographics
NPI:1831194737
Name:BANITT, PETER FREDERICK (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:FREDERICK
Last Name:BANITT
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 1:541 NE 20TH AVE STE 225
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2895
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:19260 SW 65TH AVE STE 420
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-5712
Practice Address - Country:US
Practice Address - Phone:503-692-0405
Practice Address - Fax:503-274-5400
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD21525207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1092913Medicaid
OR139455Medicaid
OR804330003OtherBLUE CROSS BLUE SHIELD
OR111266Medicare ID - Type Unspecified
WA1092913Medicaid