Basic Information
Provider Information
NPI: 1003009861
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BANNA
FirstName: MOUSTAFA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
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
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207RC0000X45263AZY Allopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
207RC0000XP6136TXN Allopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
390200000XMT186538PAN Student, Health CareStudent in an Organized Health Care Education/Training Program 

ID Information
IDTypeStateIssuerDescription
32441390105TX MEDICAID
32441390205TX MEDICAID


Home