Provider Demographics
NPI:1487760633
Name:BANTHER, GEORGIA M (RD/LD)
Entity type:Individual
Prefix:
First Name:GEORGIA
Middle Name:M
Last Name:BANTHER
Suffix:
Gender:F
Credentials:RD/LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701
Mailing Address - Country:US
Mailing Address - Phone:580-924-3400
Mailing Address - Fax:580-924-7732
Practice Address - Street 1:1610 W UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-3045
Practice Address - Country:US
Practice Address - Phone:580-924-3400
Practice Address - Fax:580-924-7732
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK725372133V00000X
OK733133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK0192410001Medicare ID - Type Unspecified