Provider Demographics
NPI:1720379720
Name:BANAHAN, JOHN A JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:BANAHAN
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 1:1365 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39567-6604
Mailing Address - Country:US
Mailing Address - Phone:228-762-1353
Mailing Address - Fax:228-762-1359
Practice Address - Street 1:2809 DENNY AVE
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39581-5301
Practice Address - Country:US
Practice Address - Phone:228-762-1353
Practice Address - Fax:228-762-1359
Is Sole Proprietor?:No
Enumeration Date:2011-04-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS247962085R0202X
AL320652085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology