Healthcare Provider Details

I. General information

NPI: 1407485311
Provider Name (Legal Business Name): VIBHU BANALA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2020
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E 210TH ST
BRONX NY
10467-2401
US

IV. Provider business mailing address

1500 OWENS ST STE 430
SAN FRANCISCO CA
94158-2335
US

V. Phone/Fax

Practice location:
  • Phone: 718-920-2060
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberA201632
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: