Provider Demographics
NPI:1770567109
Name:BANISTER, MELINDA D (MD)
Entity type:Individual
Prefix:DR
First Name:MELINDA
Middle Name:D
Last Name:BANISTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4505 15TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79416-4809
Mailing Address - Country:US
Mailing Address - Phone:806-793-3510
Mailing Address - Fax:
Practice Address - Street 1:4505 15TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79416-4809
Practice Address - Country:US
Practice Address - Phone:806-793-3510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6775208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G0352OtherBC/BS
NM73734322Medicaid
TX101068101Medicaid
OK200010850AMedicaid
TX101068100OtherFIRSTCARE COMMERCIAL
TX158778402Medicaid
TX158778401Medicaid
TX87380ZOtherHMO BLUE
NMA564OtherTRIWEST
NM201042058OtherPRESBYTERIAN COMMERCIAL
NM201042058Medicaid
NM201042058OtherPRESBYTERIAN COMMERCIAL
TXH86821Medicare UPIN
TX8A8348Medicare ID - Type Unspecified