Provider Demographics
NPI:1083918361
Name:BANASZAK, TERRANCE EDWARD JR (DO)
Entity Type:Individual
Prefix:
First Name:TERRANCE
Middle Name:EDWARD
Last Name:BANASZAK
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:335 GLESSNER AVE RM 325E
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-2269
Mailing Address - Country:US
Mailing Address - Phone:419-520-2495
Mailing Address - Fax:419-520-2496
Practice Address - Street 1:4343 ALL SEASONS DR STE 160
Practice Address - Street 2:
Practice Address - City:HILLIARD
Practice Address - State:OH
Practice Address - Zip Code:43026
Practice Address - Country:US
Practice Address - Phone:614-541-2676
Practice Address - Fax:614-541-2678
Is Sole Proprietor?:No
Enumeration Date:2010-12-31
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH58003673207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0106005Medicaid