Basic Information
| Provider Information | |||||||||
| NPI: | 1316259179 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DARYL P BANTA M.D., INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 50148 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911150148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264860181 | ||||||||
| FaxNumber: | 6264860189 | ||||||||
| Practice Location | |||||||||
| Address1: | 39 CONGRESS ST STE 201A | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911053021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264860181 | ||||||||
| FaxNumber: | 6264860189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2010 | ||||||||
| LastUpdateDate: | 08/09/2011 | ||||||||
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| AuthorizedOfficialLastName: | BANTA | ||||||||
| AuthorizedOfficialFirstName: | DARYL | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 6264860181 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D., | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RC0200X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | CH151A | 01 | CA | MEDICARE NUMBER | OTHER |