Provider Demographics
NPI:1023042637
Name:BANAAG, ERNESTO BELMONTE (MD)
Entity Type:Individual
Prefix:DR
First Name:ERNESTO
Middle Name:BELMONTE
Last Name:BANAAG
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 1:4034 VERDUGO RD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90065-3727
Mailing Address - Country:US
Mailing Address - Phone:323-254-1987
Mailing Address - Fax:323-254-3674
Practice Address - Street 1:4034 VERDUGO RD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90065-3727
Practice Address - Country:US
Practice Address - Phone:323-254-1987
Practice Address - Fax:323-254-3674
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA36730207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA36730AOtherMEDICARE PPIN
CA00A367300Medicaid
CAW20256OtherGROUP MEDICARE ID
CAA28165Medicare UPIN
CAA36730Medicare ID - Type Unspecified