Provider Demographics
NPI:1205861374
Name:BANKS, KAREN A
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:A
Last Name:BANKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:A
Other - Last Name:MALLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:503 GORDON AVE
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-6645
Mailing Address - Country:US
Mailing Address - Phone:229-227-1999
Mailing Address - Fax:229-227-0035
Practice Address - Street 1:503 GORDON AVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-6645
Practice Address - Country:US
Practice Address - Phone:229-227-1999
Practice Address - Fax:229-227-0035
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000651213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA2386156OtherCIGNA
GA000477628AMedicaid
480012672OtherRAILROAD MEDICARE
480025966OtherRAILROAD MEDICARE
10616659OtherCAQH
GA5210038OtherAETNA
GA000477628AMedicaid
GA48SCBJMMedicare PIN
480025966OtherRAILROAD MEDICARE