Provider Demographics
NPI:1912389891
Name:BANISTER, ELYSE (OD)
Entity Type:Individual
Prefix:
First Name:ELYSE
Middle Name:
Last Name:BANISTER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8900 SE 165TH MULBERRY LN
Mailing Address - Street 2:
Mailing Address - City:THE VILLAGES
Mailing Address - State:FL
Mailing Address - Zip Code:32162-5884
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8900 SE 165TH MULBERRY LN
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32162-5884
Practice Address - Country:US
Practice Address - Phone:352-674-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-26
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT003042152W00000X
PAOEG003056152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist