Healthcare Provider Details

I. General information

NPI: 1699884890
Provider Name (Legal Business Name): CHANTAY BANIKARIM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 04/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 W THOMAS RD SUITE 301
PHOENIX AZ
85013-4419
US

IV. Provider business mailing address

FILE 56765
LOS ANGELES CA
90074-6765
US

V. Phone/Fax

Practice location:
  • Phone: 602-406-4772
  • Fax:
Mailing address:
  • Phone: 602-406-3860
  • Fax: 602-406-6132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number30080
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: