Provider Demographics
NPI:1366427064
Name:BANUELOS, ELIAS IGNACIO (MD)
Entity type:Individual
Prefix:
First Name:ELIAS
Middle Name:IGNACIO
Last Name:BANUELOS
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 1:1141 PEAR TREE LN STE 100
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-6485
Mailing Address - Country:US
Mailing Address - Phone:707-254-1770
Mailing Address - Fax:
Practice Address - Street 1:911 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CALISTOGA
Practice Address - State:CA
Practice Address - Zip Code:94515-1433
Practice Address - Country:US
Practice Address - Phone:707-709-2308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME97139207Q00000X
CAA72691207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A726910Medicaid
CA00A726910Medicaid
FL00A726910Medicare PIN