Provider Demographics
NPI:1003009861
Name:BANNA, MOUSTAFA (MD)
Entity Type:Individual
Prefix:
First Name:MOUSTAFA
Middle Name:
Last Name:BANNA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13460 N 94TH DR STE J1
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4246
Mailing Address - Country:US
Mailing Address - Phone:623-876-8816
Mailing Address - Fax:623-298-0168
Practice Address - Street 1:13460 N 94TH DR STE J1
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4246
Practice Address - Country:US
Practice Address - Phone:623-876-8816
Practice Address - Fax:623-298-0168
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ45263207RC0000X, 207RC0000X
TXP6136207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ040629Medicaid
TX324413902Medicaid
TX324413902Medicaid
TX306459YKP5Medicare PIN