Provider Demographics
NPI:1194828491
Name:BANNWART, PHILIPP LEO (MD)
Entity Type:Individual
Prefix:
First Name:PHILIPP
Middle Name:LEO
Last Name:BANNWART
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 1:2500 ALHAMBRA AVE
Mailing Address - Street 2:CCRMC, ATT. MED STAFF,
Mailing Address - City:MARTINEZ
Mailing Address - State:CA
Mailing Address - Zip Code:94553-3156
Mailing Address - Country:US
Mailing Address - Phone:925-370-5110
Mailing Address - Fax:
Practice Address - Street 1:2500 ALHAMBRA AVE
Practice Address - Street 2:ATT MED STAFF @ CCRMC
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553-3156
Practice Address - Country:US
Practice Address - Phone:925-370-5110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA83871207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine