Provider Demographics
NPI:1700990132
Name:BANNISTER, JOHNNY (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHNNY
Middle Name:
Last Name:BANNISTER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:LEE
Other - Last Name:BANNISTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:2913 MOORCROFT DR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36116-3311
Mailing Address - Country:US
Mailing Address - Phone:334-272-4670
Mailing Address - Fax:334-273-6254
Practice Address - Street 1:215 PERRY HILL RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36109-3725
Practice Address - Country:US
Practice Address - Phone:334-272-4670
Practice Address - Fax:334-273-6254
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALAL-S496152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist