Healthcare Provider Details

I. General information

NPI: 1568440295
Provider Name (Legal Business Name): LAWRENCE ESTEL BANTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: LARRY ESTEL BANTA M.D.

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 02/10/2022
Certification Date: 11/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 FAIRVIEW AVE SUITE 200
CALDWELL ID
83605-5407
US

IV. Provider business mailing address

PO BOX 277976
ATLANTA GA
30384-7976
US

V. Phone/Fax

Practice location:
  • Phone: 208-459-4667
  • Fax: 208-442-6520
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberM-5243
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: