Provider Demographics
NPI:1669526729
Name:BANTA, PAUL E (MD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:E
Last Name:BANTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:663 MIDVALE AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-2337
Mailing Address - Country:US
Mailing Address - Phone:310-208-5182
Mailing Address - Fax:310-208-2003
Practice Address - Street 1:663 MIDVALE AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-2337
Practice Address - Country:US
Practice Address - Phone:310-208-5182
Practice Address - Fax:310-208-2003
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG55468207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G554680Medicaid
CAG55468AMedicare ID - Type Unspecified
CAG55468BMedicare ID - Type Unspecified