Provider Demographics
NPI:1659419745
Name:BANULL, KATHERINE GIBBS (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:GIBBS
Last Name:BANULL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KATHERINE
Other - Middle Name:ANNA
Other - Last Name:GIBBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 10744
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33757-8744
Mailing Address - Country:US
Mailing Address - Phone:727-532-0002
Mailing Address - Fax:
Practice Address - Street 1:3251 N MCMULLEN BOOTH RD
Practice Address - Street 2:SUITE 104
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33761-2022
Practice Address - Country:US
Practice Address - Phone:727-799-0415
Practice Address - Fax:813-635-7941
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88497207RI0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269065900Medicaid
FL269065900Medicaid
FLI14641Medicare UPIN