Provider Demographics
NPI:1669600219
Name:BANNO, MARK KOREA (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:KOREA
Last Name:BANNO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MOUWAFAK
Other - Middle Name:K
Other - Last Name:BANNO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:27970 ORCHARD LAKE RD STE 1
Mailing Address - Street 2:FARMINGTON HILLS MEDICAL GROUP
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-3767
Mailing Address - Country:US
Mailing Address - Phone:248-626-1999
Mailing Address - Fax:248-626-7555
Practice Address - Street 1:27970 ORCHARD LAKE RD STE 1
Practice Address - Street 2:FARMINGTON HILLS MEDICAL GROUP
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-3767
Practice Address - Country:US
Practice Address - Phone:248-626-1999
Practice Address - Fax:248-626-7555
Is Sole Proprietor?:No
Enumeration Date:2009-06-22
Last Update Date:2014-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301094195207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P33970011OtherMEDICARE P-TAN