Basic Information
| Provider Information | |||||||||
| NPI: | 1003009861 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANNA | ||||||||
| FirstName: | MOUSTAFA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5859 W. TALAVI BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853061869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022987777 | ||||||||
| FaxNumber: | 6239306060 | ||||||||
| Practice Location | |||||||||
| Address1: | 5859 W. TALAVI BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853061869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022987777 | ||||||||
| FaxNumber: | 6239306060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2007 | ||||||||
| LastUpdateDate: | 11/16/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | MT186538 | PA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RC0000X | P6136 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 45263 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 324413901 | 05 | TX | MEDICAID | 324413902 | 05 | TX | MEDICAID |