Provider Demographics
NPI:1588631493
Name:BANKS, GARRY G (MD PA)
Entity Type:Individual
Prefix:
First Name:GARRY
Middle Name:G
Last Name:BANKS
Suffix:
Gender:M
Credentials:MD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:552 TWIN CITIES BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578
Mailing Address - Country:US
Mailing Address - Phone:850-678-7676
Mailing Address - Fax:850-678-8240
Practice Address - Street 1:552 TWIN CITIES BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578
Practice Address - Country:US
Practice Address - Phone:850-678-7676
Practice Address - Fax:850-678-8240
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-01
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0062947207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL18684YMedicare UPIN
18684Medicare PIN
FLBO255AMedicare UPIN
F54795Medicare UPIN
FLF54795Medicare UPIN