Healthcare Provider Details

I. General information

NPI: 1316259179
Provider Name (Legal Business Name): DARYL P BANTA M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2010
Last Update Date: 08/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 CONGRESS ST STE 201A
PASADENA CA
91105-3021
US

IV. Provider business mailing address

PO BOX 50148
PASADENA CA
91115-0148
US

V. Phone/Fax

Practice location:
  • Phone: 626-486-0181
  • Fax: 626-486-0189
Mailing address:
  • Phone: 626-486-0181
  • Fax: 626-486-0189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DARYL P BANTA
Title or Position: DOCTOR
Credential: M.D.,
Phone: 626-486-0181