Provider Demographics
NPI:1063588739
Name:BANAS, JEFFREY RICHARD (DC)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:RICHARD
Last Name:BANAS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2055
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85214
Mailing Address - Country:US
Mailing Address - Phone:480-633-6837
Mailing Address - Fax:480-393-0928
Practice Address - Street 1:4540 E BASELINE RD STE 106
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4616
Practice Address - Country:US
Practice Address - Phone:480-633-6837
Practice Address - Fax:480-393-0928
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5396111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ043563Medicare UPIN
AZ64433Medicare ID - Type Unspecified