Provider Demographics
NPI:1619984523
Name:BANTON, MICHAEL R (MD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:R
Last Name:BANTON
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 1:13100 MANCHESTER RD STE 150
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-1743
Mailing Address - Country:US
Mailing Address - Phone:314-692-7886
Mailing Address - Fax:314-692-7929
Practice Address - Street 1:13100 MANCHESTER RD STE 150
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-1743
Practice Address - Country:US
Practice Address - Phone:314-692-7886
Practice Address - Fax:314-692-7929
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2017-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR1J812084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1511221OtherUNITED HEALTHCARE
MO202842001Medicaid
MO260012274OtherCHAMPUS
MO132484OtherHEALTHLINK
MO4222764OtherAETNA
MO23064OtherBLUE SHEILD
MO001011488Medicare ID - Type Unspecified
MO23064OtherBLUE SHEILD