Provider Demographics
NPI:1235813650
Name:BANAWOE, GAETAN
Entity Type:Individual
Prefix:
First Name:GAETAN
Middle Name:
Last Name:BANAWOE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 E 9TH ST UNIT 615
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-3543
Mailing Address - Country:US
Mailing Address - Phone:434-996-6124
Mailing Address - Fax:
Practice Address - Street 1:9841 NORTHLAKE CENTRE PKWY
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216-8930
Practice Address - Country:US
Practice Address - Phone:704-598-2468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2415152W00000X
NC2775152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2775OtherOPTOMETRY LICENSE