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: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 PENNELL RD STE C
MEDIA PA
19063-6502
US

IV. Provider business mailing address

18444 N 25TH AVE STE 310
PHOENIX AZ
85023-1266
US

V. Phone/Fax

Practice location:
  • Phone: 610-876-0347
  • Fax: 833-941-3871
Mailing address:
  • Phone: 623-241-8716
  • Fax: 480-499-8459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License NumberMD495745
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberA201632
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: