Basic Information
| Provider Information | |||||||||
| NPI: | 1053417956 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANNISTER | ||||||||
| FirstName: | RON | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 102 S DAWSON ST | ||||||||
| Address2: | |||||||||
| City: | THOMASVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317925185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292269190 | ||||||||
| FaxNumber: | 2292268824 | ||||||||
| Practice Location | |||||||||
| Address1: | 15196 US HIGHWAY 19 S | ||||||||
| Address2: | |||||||||
| City: | THOMASVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317574820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292284770 | ||||||||
| FaxNumber: | 2292259060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 02/15/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT000844 | GA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 0271120001 | 01 | GA | DME-MEDICARE | OTHER | 40064 | 01 | GA | AVESIS PIN | OTHER | 000139334A | 05 | GA | MEDICAID |