Individual
TRAVIS BRUCE BANTA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
5000 HENNESSY BLVD, BATON ROUGE, LA 70808
(225) 757-0552
(225) 763-9997
Mailing address
8230 SUMMA AVE STE C, BATON ROUGE, LA 70809-3465
(225) 757-0552
(225) 763-9997
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
331083
LA
2085R0202X
Diagnostic Radiology Physician
91576
GA
2085R0202X
Diagnostic Radiology Physician
T-3287
MS
390200000X
Student in an Organized Health Care Education/Training Program
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Other
Enumeration date
03/28/2017
Last updated
10/20/2022
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