Provider Demographics
NPI:1316035355
Name:BANJANIN, MILAN (MD)
Entity Type:Individual
Prefix:
First Name:MILAN
Middle Name:
Last Name:BANJANIN
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:PO BOX 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:360-734-4404
Mailing Address - Fax:360-734-7409
Practice Address - Street 1:3130 ELLIS ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1904
Practice Address - Country:US
Practice Address - Phone:360-734-4404
Practice Address - Fax:360-734-7409
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00030759174400000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8178238Medicaid
WA8178238Medicaid
WA001484009Medicare ID - Type Unspecified