Healthcare Provider Details

I. General information

NPI: 1366427064
Provider Name (Legal Business Name): ELIAS IGNACIO BANUELOS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 09/29/2022
Certification Date: 09/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 WASHINGTON ST
CALISTOGA CA
94515-1433
US

IV. Provider business mailing address

1141 PEAR TREE LN STE 100
NAPA CA
94558-6485
US

V. Phone/Fax

Practice location:
  • Phone: 707-709-2308
  • Fax:
Mailing address:
  • Phone: 707-254-1770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME97139
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA72691
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: