Provider Demographics
NPI:1598784662
Name:BANNOUT, MIKE M (MD)
Entity Type:Individual
Prefix:DR
First Name:MIKE
Middle Name:M
Last Name:BANNOUT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:DEPT 34929
Mailing Address - Street 2:P.O. BOX 39000
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94139-0001
Mailing Address - Country:US
Mailing Address - Phone:925-952-2828
Mailing Address - Fax:925-952-2850
Practice Address - Street 1:2700 GRANT ST
Practice Address - Street 2:SUITE 200
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-2266
Practice Address - Country:US
Practice Address - Phone:925-674-2609
Practice Address - Fax:925-674-2211
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2012-06-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA61793207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A617930Medicaid
CAAM796Z-TRAUMAMedicare PIN
CA00A617930Medicaid
CAP0055641Medicare PIN
CA00A617934Medicare PIN