Provider Demographics
NPI:1376538629
Name:BANISTER, HEIDI L (MD)
Entity Type:Individual
Prefix:DR
First Name:HEIDI
Middle Name:L
Last Name:BANISTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18555 N. 79TH AVE
Mailing Address - Street 2:B108
Mailing Address - City:GLENDAL
Mailing Address - State:AZ
Mailing Address - Zip Code:85308
Mailing Address - Country:US
Mailing Address - Phone:623-773-2848
Mailing Address - Fax:623-773-0370
Practice Address - Street 1:PO BOX 11447
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85318-1447
Practice Address - Country:US
Practice Address - Phone:623-773-2848
Practice Address - Fax:623-773-0370
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30245207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ74706Medicare PIN
AZH83334Medicare UPIN