Provider Demographics
NPI:1134112618
Name:BANKS-JACKSON, ROSLYN C (MD)
Entity Type:Individual
Prefix:MS
First Name:ROSLYN
Middle Name:C
Last Name:BANKS-JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ROSLYN
Other - Middle Name:C
Other - Last Name:BANKS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2400 BELLEVUE RD
Mailing Address - Street 2:STE 23
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-2888
Mailing Address - Country:US
Mailing Address - Phone:478-272-8580
Mailing Address - Fax:478-275-0012
Practice Address - Street 1:1061 HARMON AVE
Practice Address - Street 2:
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314
Practice Address - Country:US
Practice Address - Phone:912-435-6965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036121554207V00000X
GA051865207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H70281Medicare UPIN
NC2050117AMedicare PIN