Provider Demographics
NPI:1962479451
Name:BANEZ, MONICO PETER (MD)
Entity type:Individual
Prefix:
First Name:MONICO
Middle Name:PETER
Last Name:BANEZ
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 1:1804 HIGHWAY 45 BYP
Mailing Address - Street 2:SUITE 604
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-4436
Mailing Address - Country:US
Mailing Address - Phone:731-660-8759
Mailing Address - Fax:
Practice Address - Street 1:620 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3923
Practice Address - Country:US
Practice Address - Phone:731-660-8759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS27436208M00000X
TN35303207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3889132Medicaid
4070560OtherBCBS
P00077531OtherRR MEDICARE
P00077531OtherRR MEDICARE
4070560OtherBCBS