Provider Demographics
NPI:1235418807
Name:BAMBAN, JOHN MACKERTICH (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MACKERTICH
Last Name:BAMBAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10028B FOURNIER AVE
Mailing Address - Street 2:
Mailing Address - City:DIBERVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39540-5424
Mailing Address - Country:US
Mailing Address - Phone:770-733-5205
Mailing Address - Fax:
Practice Address - Street 1:11516 LAMEY BRIDGE RD STE E
Practice Address - Street 2:
Practice Address - City:DIBERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39540-2725
Practice Address - Country:US
Practice Address - Phone:228-207-6427
Practice Address - Fax:228-207-6428
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-12
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1179111NN1001X, 111NS0005X, 111NR0400X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NN1001XChiropractic ProvidersChiropractorNutrition
No111NS0005XChiropractic ProvidersChiropractorSports Physician
No111NR0400XChiropractic ProvidersChiropractorRehabilitation