Provider Demographics
NPI:1710987904
Name:BANTI, GUSTAVO MIGUEL (MD)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:MIGUEL
Last Name:BANTI
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 1:2234 COLONIAL BLVD
Mailing Address - Street 2:ATTN: PAYER CONTRACTING & RELATIONS DEPT.
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:1281 E COTTONWOOD LN
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-2949
Practice Address - Country:US
Practice Address - Phone:520-876-0150
Practice Address - Fax:520-421-3474
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036063412208800000X
AZ47007208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2136778OtherCIGNA
AZ328075OtherUNIVERSAL HEALTHCARE
IL036063412Medicaid
IL4500628OtherBCBS
AZ776955Medicaid
AZP01137572OtherRAILROAD MCR
AZ4016817OtherAETNA
AZ776955Medicaid
AZ2136778OtherCIGNA
K04276Medicare PIN
IL4500628OtherBCBS