Provider Demographics
NPI:1679693741
Name:BANO, ELISA (OD)
Entity type:Individual
Prefix:
First Name:ELISA
Middle Name:
Last Name:BANO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5001 FRANKFORD AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19124-2619
Mailing Address - Country:US
Mailing Address - Phone:215-288-5000
Mailing Address - Fax:215-744-1233
Practice Address - Street 1:5001 FRANKFORD AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-2619
Practice Address - Country:US
Practice Address - Phone:215-288-5000
Practice Address - Fax:215-744-1233
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002681152W00000X
MA5793183700000X
NJ27OA00851100152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAOEG002681OtherLICENSE