Provider Demographics
NPI:1407894421
Name:BANULL, CRAIG M (M D)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:M
Last Name:BANULL
Suffix:
Gender:M
Credentials:M D
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 917368
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:727-793-9300
Mailing Address - Fax:727-793-0052
Practice Address - Street 1:1106 DRUID RD S
Practice Address - Street 2:SUITE 302
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-3846
Practice Address - Country:US
Practice Address - Phone:727-441-3711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME921122085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL16163OtherBLUE CROSS BLUE SHIELD
FLP00358083OtherRR MEDICARE
FL272753600Medicaid
FL16163Medicare ID - Type UnspecifiedMEDICARE NUMBER
FLP00358083OtherRR MEDICARE