Provider Demographics
NPI:1568440295
Name:BANTA, LAWRENCE ESTEL (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:ESTEL
Last Name:BANTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:LARRY
Other - Middle Name:ESTEL
Other - Last Name:BANTA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 277976
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-7976
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1906 FAIRVIEW AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-5407
Practice Address - Country:US
Practice Address - Phone:208-459-4667
Practice Address - Fax:208-442-6520
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-52432084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
C-47913Medicare UPIN