Provider Demographics
NPI:1558497040
Name:LIZA DE OLAZO BANAAG, M. D., P. A.
Entity Type:Organization
Organization Name:LIZA DE OLAZO BANAAG, M. D., P. A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LIZA
Authorized Official - Middle Name:DE OLAZO
Authorized Official - Last Name:BANAAG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:832-646-5492
Mailing Address - Street 1:PO BOX 2329
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38902-2329
Mailing Address - Country:US
Mailing Address - Phone:832-646-5492
Mailing Address - Fax:
Practice Address - Street 1:965 J K AVENT DR
Practice Address - Street 2:SUITE 100-A
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-5045
Practice Address - Country:US
Practice Address - Phone:662-227-7446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS197482083P0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00113JMedicare ID - Type Unspecified
TXG79717Medicare UPIN