Basic Information
| Provider Information | |||||||||
| NPI: | 1417335498 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BANZON | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1193 NORTON AVE STE A | ||||||||
| Address2: | |||||||||
| City: | NORTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442039526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308251152 | ||||||||
| FaxNumber: | 3308540829 | ||||||||
| Practice Location | |||||||||
| Address1: | 944 CHERRY ST E | ||||||||
| Address2: | |||||||||
| City: | CANAL FULTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446148669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308544574 | ||||||||
| FaxNumber: | 3308540829 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2015 | ||||||||
| LastUpdateDate: | 08/10/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35.132627 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0305269 | 05 | OH | MEDICAID |