Provider Demographics
NPI:1811945439
Name:BANWART, BRUCE DOUGLAS (MD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:DOUGLAS
Last Name:BANWART
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 1:1417 S CLIFF AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-1009
Mailing Address - Country:US
Mailing Address - Phone:605-322-3666
Mailing Address - Fax:
Practice Address - Street 1:1417 S CLIFF AVE STE 201
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1009
Practice Address - Country:US
Practice Address - Phone:605-322-3666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20150086102080P0203X
SD124152080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205855109Medicaid
KS100421570AMedicaid
MO205855109Medicaid