Provider Demographics
NPI:1598750747
Name:BANAS, JON MICHAEL (DO)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:MICHAEL
Last Name:BANAS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3660 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-8005
Mailing Address - Country:US
Mailing Address - Phone:239-936-2316
Mailing Address - Fax:239-931-6365
Practice Address - Street 1:3680 BROADWAY
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-8005
Practice Address - Country:US
Practice Address - Phone:239-936-2316
Practice Address - Fax:239-931-6365
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2011-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361004312085R0202X
FLOS105602085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00801888OtherRAILROAD MEDICARE
FL001495200Medicaid
IL036100431Medicaid
FL001495200Medicaid
H07213Medicare UPIN
ILL70705Medicare ID - Type Unspecified
FLP00801888OtherRAILROAD MEDICARE