Provider Demographics
NPI:1801867254
Name:BANOWETZ, JOHN MIKE (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MIKE
Last Name:BANOWETZ
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 1:4401 W MEMORIAL RD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1785
Mailing Address - Country:US
Mailing Address - Phone:405-752-3162
Mailing Address - Fax:
Practice Address - Street 1:4120 W MEMORIAL RD
Practice Address - Street 2:#218
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120
Practice Address - Country:US
Practice Address - Phone:405-302-2661
Practice Address - Fax:405-302-2670
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101842084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100128980AMedicaid
OKE08007Medicare UPIN