Provider Demographics
NPI:1093044794
Name:LESAN BANKO, M.D. INC.
Entity Type:Organization
Organization Name:LESAN BANKO, M.D. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LESANEMARIE
Authorized Official - Middle Name:T
Authorized Official - Last Name:BANKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-843-7675
Mailing Address - Street 1:12984 HESPERIA RD STE 100
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-5819
Mailing Address - Country:US
Mailing Address - Phone:760-843-7675
Mailing Address - Fax:760-843-7649
Practice Address - Street 1:12984 HESPERIA RD STE 100
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-5819
Practice Address - Country:US
Practice Address - Phone:760-843-7675
Practice Address - Fax:760-843-7649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA104321207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty