Healthcare Provider Details

I. General information

NPI: 1962479451
Provider Name (Legal Business Name): MONICO PETER BANEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2006
Last Update Date: 08/15/2022
Certification Date: 08/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 SKYLINE DR
JACKSON TN
38301-3923
US

IV. Provider business mailing address

1804 HIGHWAY 45 BYP SUITE 604
JACKSON TN
38305-4436
US

V. Phone/Fax

Practice location:
  • Phone: 731-660-8759
  • Fax:
Mailing address:
  • Phone: 731-660-8759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number27436
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35303
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: