Provider Demographics
NPI:1508863051
Name:BANAS, THOMAS MARK (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:MARK
Last Name:BANAS
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 1:7956 WEST JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4159
Mailing Address - Country:US
Mailing Address - Phone:260-436-2416
Mailing Address - Fax:260-436-9662
Practice Address - Street 1:7956 WEST JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4159
Practice Address - Country:US
Practice Address - Phone:260-436-2416
Practice Address - Fax:260-436-9662
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2020-039172084N0400X
IN01040131A2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0878279Medicaid
NC1508863051Medicaid
MI4132886Medicaid
IN100319490Medicaid
IN130006861OtherRR MEDICARE
E54252Medicare UPIN
OH0878279Medicaid
IN5506830001Medicare NSC
IN130006861OtherRR MEDICARE
IN668120AMedicare PIN