Provider Demographics
NPI:1871676122
Name:BANTA, MAUREEN THERESA (MD)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:THERESA
Last Name:BANTA
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 1:6609 32ND ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20015-2309
Mailing Address - Country:US
Mailing Address - Phone:301-922-0522
Mailing Address - Fax:
Practice Address - Street 1:2500 N VAN DORN ST STE 102
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22302-1601
Practice Address - Country:US
Practice Address - Phone:703-933-0555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2022-11-19
Deactivation Date:2017-11-13
Deactivation Code:
Reactivation Date:2017-11-17
Provider Licenses
StateLicense IDTaxonomies
MDD0092143208000000X
VA0101057222208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics