Provider Demographics
NPI:1891887600
Name:KEITH M BANTON MD PA
Entity Type:Organization
Organization Name:KEITH M BANTON MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:M
Authorized Official - Last Name:BANTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-763-4700
Mailing Address - Street 1:3230 E 15TH ST
Mailing Address - Street 2:UNIT B
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-7423
Mailing Address - Country:US
Mailing Address - Phone:850-763-4700
Mailing Address - Fax:850-763-4999
Practice Address - Street 1:3230 E 15TH ST
Practice Address - Street 2:UNIT B
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-7423
Practice Address - Country:US
Practice Address - Phone:850-763-4700
Practice Address - Fax:850-763-4999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85024207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL265799600Medicaid
FL13636OtherBCBS OF FLORIDA
FL13636OtherBCBS OF FLORIDA
FL265799600Medicaid