MEDICARE: DR. DWARAKNADH R BANALA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	ME80590	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1437106614
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DWARAKNADH R BANALA M.D.

Provider Business Mailing Address
First Line	:	3016 PALERMO CT
Second Line	:
City	:	MOUNT DORA
State	:	FL
Zip	:	32757-6527
Country	:	US
Telephone Number	:	352-383-8209
Fax Number	:	352-383-8209

Provider Business Practice Location Address
First Line	:	620 S LAKE ST
Second Line	:	SUITE #6
City	:	LEESBURG
State	:	FL
Zip	:	34748-6059
Country	:	US
Telephone Number	:	352-365-0099
Fax Number	:	352-315-0578

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/31/2006
Last Update Date	:	01/11/2011

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