Provider Demographics
NPI:1205896636
Name:BANTON, KEITH B (MD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:B
Last Name:BANTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3230 E 15TH ST
Mailing Address - Street 2:UNIT B
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-7423
Mailing Address - Country:US
Mailing Address - Phone:850-763-4700
Mailing Address - Fax:850-763-4999
Practice Address - Street 1:1937 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4543
Practice Address - Country:US
Practice Address - Phone:850-763-4700
Practice Address - Fax:850-763-4999
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0085024207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL265799600Medicaid
FL13636OtherBCBS OF FLORIDA
FL13636Medicare ID - Type Unspecified
FLE27284Medicare UPIN