Provider Demographics
NPI:1700835956
Name:BANASZAK, LLOYD J JR (MD)
Entity Type:Individual
Prefix:
First Name:LLOYD
Middle Name:J
Last Name:BANASZAK
Suffix:JR
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 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-5000
Mailing Address - Fax:
Practice Address - Street 1:2855 CAMPUS DR
Practice Address - Street 2:SUITE 400
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-2659
Practice Address - Country:US
Practice Address - Phone:612-577-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN277997207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN987570100Medicaid
A53303Medicare UPIN
MN80020841Medicare PIN