Provider Demographics
NPI:1972642494
Name:BANKER, HEENA (MD)
Entity type:Individual
Prefix:
First Name:HEENA
Middle Name:
Last Name:BANKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 HOPE AVE
Mailing Address - Street 2:SUITE G14
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-2721
Mailing Address - Country:US
Mailing Address - Phone:781-894-4044
Mailing Address - Fax:781-647-6411
Practice Address - Street 1:20 HOPE AVE
Practice Address - Street 2:SUITE G14
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-2721
Practice Address - Country:US
Practice Address - Phone:781-894-4044
Practice Address - Fax:781-647-6411
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA40251208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2053217Medicaid
MA2053217Medicaid