Provider Demographics
NPI:1710987904
Name:BANTI, GUSTAVO MIGUEL (MD)
Entity type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:MIGUEL
Last Name:BANTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8600 NW 41ST ST
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166-6202
Mailing Address - Country:US
Mailing Address - Phone:305-642-5366
Mailing Address - Fax:305-644-6407
Practice Address - Street 1:2020 W 64TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-2607
Practice Address - Country:US
Practice Address - Phone:305-642-5366
Practice Address - Fax:305-644-6407
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME112201208800000X
AZ47007208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ776955Medicaid
IL4500628OtherBCBS
IL036063412Medicaid
AZP01137572OtherRAILROAD MCR
AZ4016817OtherAETNA
AZ328075OtherUNIVERSAL HEALTHCARE
AZ2136778OtherCIGNA
AZ776955Medicaid
AZ2136778OtherCIGNA
K04276Medicare PIN
IL4500628OtherBCBS