Provider Demographics
NPI:1437545837
Name:BANALES, JESSE
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:BANALES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5323 HARRY HINES BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75390-7201
Mailing Address - Country:US
Mailing Address - Phone:214-476-8559
Mailing Address - Fax:
Practice Address - Street 1:333 NORTH SANTA ROAD
Practice Address - Street 2:CCF-F3725
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207
Practice Address - Country:US
Practice Address - Phone:210-704-3910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-13
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR6338208000000X, 2080N0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program