Provider Demographics
NPI:1790745297
Name:MAHANTA, BANTI (MD)
Entity Type:Individual
Prefix:
First Name:BANTI
Middle Name:
Last Name:MAHANTA
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:PO BOX 500730
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-0730
Mailing Address - Country:US
Mailing Address - Phone:303-465-0401
Mailing Address - Fax:303-404-2317
Practice Address - Street 1:1 SAINT ANTHONYS WAY
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-4568
Practice Address - Country:US
Practice Address - Phone:618-465-4520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2008-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO359782085R0202X
IL0360566112085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036056611-1Medicaid
IL300029507OtherRAILROAD MEDICARE
MO203599915Medicaid
IL036056611-1Medicaid
ILE40248Medicare UPIN
MO203599915Medicaid