Provider Demographics
NPI:1275781122
Name:EBANKS, DESMOND WALTER (MD)
Entity Type:Individual
Prefix:DR
First Name:DESMOND
Middle Name:WALTER
Last Name:EBANKS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:220 ALBANY TPKE
Mailing Address - Street 2:SUITE 164
Mailing Address - City:CANTON
Mailing Address - State:CT
Mailing Address - Zip Code:06019-2520
Mailing Address - Country:US
Mailing Address - Phone:860-748-4064
Mailing Address - Fax:860-838-2507
Practice Address - Street 1:639 PARK RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-3443
Practice Address - Country:US
Practice Address - Phone:860-748-4064
Practice Address - Fax:860-838-2507
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-04
Last Update Date:2008-09-04
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Provider Licenses
StateLicense IDTaxonomies
CT34291207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTF04438Medicare UPIN