1558497040 NPI number — LIZA DE OLAZO BANAAG, M. D., P. A.

Table of content: (NPI 1558497040)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558497040 NPI number — LIZA DE OLAZO BANAAG, M. D., P. A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIZA DE OLAZO BANAAG, M. D., P. A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558497040
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2329
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRENADA
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38902-2329
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-646-5492
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
965 J K AVENT DR
Provider Second Line Business Practice Location Address:
SUITE 100-A
Provider Business Practice Location Address City Name:
GRENADA
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38901-5045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-227-7446
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BANAAG
Authorized Official First Name:
LIZA
Authorized Official Middle Name:
DE OLAZO
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
832-646-5492

Provider Taxonomy Codes

  • Taxonomy code: 2083P0011X , with the licence number:  19748 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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