Basic Information
| Provider Information | |||||||||
| NPI: | 1366427064 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANUELOS | ||||||||
| FirstName: | ELIAS | ||||||||
| MiddleName: | IGNACIO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1141 PEAR TREE LN STE 100 | ||||||||
| Address2: | |||||||||
| City: | NAPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945586485 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072541770 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 911 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | CALISTOGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945151433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7077092308 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2005 | ||||||||
| LastUpdateDate: | 09/29/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME97139 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | A72691 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A726910 | 05 | CA | MEDICAID |