Provider Demographics
NPI:1558093591
Name:BANNISTER, ELIJAH ALLAN JACKSON (OD)
Entity Type:Individual
Prefix:
First Name:ELIJAH
Middle Name:ALLAN JACKSON
Last Name:BANNISTER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1939
Mailing Address - Street 2:
Mailing Address - City:KALAMA
Mailing Address - State:WA
Mailing Address - Zip Code:98625-1700
Mailing Address - Country:US
Mailing Address - Phone:360-560-5322
Mailing Address - Fax:
Practice Address - Street 1:820 OCEAN BEACH HWY STE 100
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-4081
Practice Address - Country:US
Practice Address - Phone:360-636-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-28
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD61311755152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist