Provider Demographics
NPI:1336218031
Name:BANISTER, JASON DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:DAVID
Last Name:BANISTER
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:PO BOX 636961
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6961
Mailing Address - Country:US
Mailing Address - Phone:513-981-5130
Mailing Address - Fax:513-981-5015
Practice Address - Street 1:225 MEDICAL CENTER DR
Practice Address - Street 2:STE 205
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-7907
Practice Address - Country:US
Practice Address - Phone:270-441-4462
Practice Address - Fax:270-441-4461
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY32967208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64027147Medicaid
KY64027147Medicaid
KYK082520Medicare PIN