Provider Demographics
NPI:1720395171
Name:BANOTH, PRAMEELA (MD)
Entity Type:Individual
Prefix:
First Name:PRAMEELA
Middle Name:
Last Name:BANOTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 HOLMES ST STE 800
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64108-2602
Mailing Address - Country:US
Mailing Address - Phone:816-218-2500
Mailing Address - Fax:
Practice Address - Street 1:2301 HOLMES ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64108-2640
Practice Address - Country:US
Practice Address - Phone:816-404-4070
Practice Address - Fax:816-404-4075
Is Sole Proprietor?:No
Enumeration Date:2010-09-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012019401207R00000X, 207RN0300X
IL125055676207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR193710001Medicaid
MO1720395171Medicaid
MO431560263OtherTRICARE
MOP01085133OtherMCR RR
AR193710001Medicaid