Provider Demographics
NPI:1689824856
Name:BANNWARTH, JOHN HERBERT (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:HERBERT
Last Name:BANNWARTH
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 1:25134 CAMPGROUND RD
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:SD
Mailing Address - Zip Code:57301-7829
Mailing Address - Country:US
Mailing Address - Phone:605-999-9451
Mailing Address - Fax:
Practice Address - Street 1:4501 E ARROWHEAD PKWY
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57110-2701
Practice Address - Country:US
Practice Address - Phone:605-999-9451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-24
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD659152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist