Provider Demographics
NPI:1649231366
Name:BANNERMAN, ALFRED CLAYTON (MD)
Entity type:Individual
Prefix:MR
First Name:ALFRED
Middle Name:CLAYTON
Last Name:BANNERMAN
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 1:180 SALEM ROAD
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590
Mailing Address - Country:US
Mailing Address - Phone:516-997-3269
Mailing Address - Fax:
Practice Address - Street 1:8900 VAN WYCK EXPRESSWAY
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11418-2832
Practice Address - Country:US
Practice Address - Phone:718-206-7089
Practice Address - Fax:718-206-7055
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1111422084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO14071762Medicaid
NM42551056Medicaid
AZ084255Medicaid
CO14071762Medicaid
8HF278Medicare PIN
8HF277Medicare PIN
NYG400132066Medicare PIN
AZ084255Medicaid