Provider Demographics
NPI:1659379717
Name:BANERJI, BASHAB (MD)
Entity Type:Individual
Prefix:DR
First Name:BASHAB
Middle Name:
Last Name:BANERJI
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 1:5731 SOUTH FORT APACHE ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148
Mailing Address - Country:US
Mailing Address - Phone:702-740-5311
Mailing Address - Fax:702-740-5310
Practice Address - Street 1:5731 S FORT APACHE RD STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-5620
Practice Address - Country:US
Practice Address - Phone:702-740-5311
Practice Address - Fax:702-740-5310
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2019-07-03
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-21
Provider Licenses
StateLicense IDTaxonomies
NV9544207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002018282Medicaid
NV38618Medicare ID - Type Unspecified
NEG90898Medicare UPIN