Provider Demographics
NPI:1932299450
Name:BANTA, DARYL (MD)
Entity Type:Individual
Prefix:
First Name:DARYL
Middle Name:
Last Name:BANTA
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 1:39 CONGRESS ST
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3024
Mailing Address - Country:US
Mailing Address - Phone:626-486-0181
Mailing Address - Fax:866-765-3604
Practice Address - Street 1:10 CONGRESS ST STE 155
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3045
Practice Address - Country:US
Practice Address - Phone:626-486-0181
Practice Address - Fax:626-486-0189
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA88722207RC0200X, 207RP1001X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease