Basic Information
| Provider Information | |||||||||
| NPI: | 1659419745 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BANULL | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | GIBBS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GIBBS | ||||||||
| OtherFirstName: | KATHERINE | ||||||||
| OtherMiddleName: | ANNA | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 10744 | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337578744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275320002 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3251 N MCMULLEN BOOTH RD | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337612022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277990415 | ||||||||
| FaxNumber: | 8136357941 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 07/20/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | ME88497 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207R00000X | ME88497 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 269065900 | 05 | FL | MEDICAID |