Provider Demographics
NPI:1124366299
Name:BANUELOS FAMILY MEDICINE, LLC
Entity Type:Organization
Organization Name:BANUELOS FAMILY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIAS
Authorized Official - Middle Name:IGNACIO
Authorized Official - Last Name:BANUELOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-983-8500
Mailing Address - Street 1:6061 DOCTORS PARK
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32570-5073
Mailing Address - Country:US
Mailing Address - Phone:850-983-8500
Mailing Address - Fax:850-983-0009
Practice Address - Street 1:6061 DOCTORS PARK
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32570-5073
Practice Address - Country:US
Practice Address - Phone:850-983-8500
Practice Address - Fax:850-983-0009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-24
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME97139207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty