Provider Demographics
NPI:1255383485
Name:BANALES, FEDERICO (MD)
Entity type:Individual
Prefix:
First Name:FEDERICO
Middle Name:
Last Name:BANALES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 TEJAS PL
Mailing Address - Street 2:
Mailing Address - City:NIPOMO
Mailing Address - State:CA
Mailing Address - Zip Code:93444-9123
Mailing Address - Country:US
Mailing Address - Phone:805-931-2556
Mailing Address - Fax:805-929-6440
Practice Address - Street 1:2801 SANTA MARIA WAY
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93455-2118
Practice Address - Country:US
Practice Address - Phone:805-934-5400
Practice Address - Fax:805-938-9207
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA526582084F0202X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1275553257Medicaid
CA1841217866Medicaid
CA1447277355Medicaid
CA051872Medicare Oscar/Certification
CAW1508EMedicare PIN
H23407Medicare UPIN
00A526580Medicare ID - Type Unspecified
CA1841217866Medicaid
CA1447277355Medicaid
CA1275553257Medicaid
CA551982Medicare Oscar/Certification