Healthcare Provider Details

I. General information

NPI: 1669536686
Provider Name (Legal Business Name): ZITA LUNA-BANIQUED M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1585 THIRD ST. BAYNE JONES ACH
FORT POLK LA
71459-5110
US

IV. Provider business mailing address

1605 AMOUR DR
LEESVILLE LA
71446-5212
US

V. Phone/Fax

Practice location:
  • Phone: 337-531-3074
  • Fax: 337-531-3709
Mailing address:
  • Phone: 337-238-9317
  • Fax: 337-531-3709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberA37780
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: