Provider Demographics
NPI:1962677781
Name:MUSSA BANISADRE MD INC
Entity Type:Organization
Organization Name:MUSSA BANISADRE MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MUSSA
Authorized Official - Middle Name:
Authorized Official - Last Name:BANISADRE
Authorized Official - Suffix:
Authorized Official - Credentials:MD INC
Authorized Official - Phone:209-524-7000
Mailing Address - Street 1:1325 MELROSE AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-5581
Mailing Address - Country:US
Mailing Address - Phone:209-527-5601
Mailing Address - Fax:
Practice Address - Street 1:1325 MELROSE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-5581
Practice Address - Country:US
Practice Address - Phone:209-527-5601
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA38740207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty