Healthcare Provider Details

I. General information

NPI: 1306208590
Provider Name (Legal Business Name): JUSTIN LEE BANAGA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2016
Last Update Date: 11/16/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 POTRERO AVENUE BLDG. 5 , 1ST FL
SAN FRANCISCO CA
94110
US

IV. Provider business mailing address

751 S BASCOM AVE
SAN JOSE CA
95128-2604
US

V. Phone/Fax

Practice location:
  • Phone: 628-206-8020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA152793
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: