Provider Demographics
NPI:1316955990
Name:BANISTER, MARK J (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:BANISTER
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:PO BOX 706
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03264-0706
Mailing Address - Country:US
Mailing Address - Phone:603-481-8757
Mailing Address - Fax:603-238-2163
Practice Address - Street 1:16 HOSPITAL ROAD
Practice Address - Street 2:PLYMOUTH OB/GYN
Practice Address - City:PLYMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03264
Practice Address - Country:US
Practice Address - Phone:603-536-1104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH10740207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0RE5597Medicaid
NH10740OtherSTATE LICENSE
NH3072661Medicaid
BB3971377OtherDEA NUMBER
F78568Medicare UPIN
DX99127Medicare PIN
NH3072661Medicaid