Provider Demographics
NPI:1619328606
Name:BANAS, JEFF (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFF
Middle Name:
Last Name:BANAS
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 1:3805B SPRING ST STE 140
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53405-1642
Mailing Address - Country:US
Mailing Address - Phone:262-637-0500
Mailing Address - Fax:262-635-8027
Practice Address - Street 1:3805B SPRING ST STE 140
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53405-1642
Practice Address - Country:US
Practice Address - Phone:262-637-0500
Practice Address - Fax:262-635-8027
Is Sole Proprietor?:No
Enumeration Date:2016-06-30
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3424152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100074192Medicaid