Healthcare Provider Details

I. General information

NPI: 1639319411
Provider Name (Legal Business Name): SUDESH BANAJI MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2009
Last Update Date: 05/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 SECOND STREET
EARLE AR
72331-1634
US

IV. Provider business mailing address

332 E COOK ST
FORREST CITY AR
72335-2830
US

V. Phone/Fax

Practice location:
  • Phone: 870-792-8825
  • Fax: 870-792-8834
Mailing address:
  • Phone: 870-630-2233
  • Fax: 870-630-2224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License NumberE2405
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. SUDESH BANAJI
Title or Position: OWNER
Credential: MD
Phone: 870-792-8825