Provider Demographics
NPI:1003815192
Name:BANAJI, SUDESH (MD)
Entity Type:Individual
Prefix:DR
First Name:SUDESH
Middle Name:
Last Name:BANAJI
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 1:332 EAST COOK STREET
Mailing Address - Street 2:
Mailing Address - City:FORREST CITY
Mailing Address - State:AR
Mailing Address - Zip Code:72335-9183
Mailing Address - Country:US
Mailing Address - Phone:870-630-2233
Mailing Address - Fax:870-630-2224
Practice Address - Street 1:332 E COOK ST
Practice Address - Street 2:
Practice Address - City:FORREST CITY
Practice Address - State:AR
Practice Address - Zip Code:72335-2830
Practice Address - Country:US
Practice Address - Phone:870-630-2233
Practice Address - Fax:870-630-2224
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-2308207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5F219OtherAR BCBS
AR138381001Medicaid
AR138381001Medicaid
AR5F219OtherAR BCBS
AR5L309Medicare UPIN