Provider Demographics
NPI:1629026190
Name:BANKS, KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:BANKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 707
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27702-0707
Mailing Address - Country:US
Mailing Address - Phone:919-255-1408
Mailing Address - Fax:919-212-9029
Practice Address - Street 1:2949 NEW BERN AVENUE
Practice Address - Street 2:SUITE 112A
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610
Practice Address - Country:US
Practice Address - Phone:919-255-1408
Practice Address - Fax:919-212-9029
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18602207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC12978OtherBLUE CROSS BLUE SHIELD
NC8912978Medicaid
NC12978OtherBLUE CROSS BLUE SHIELD
201687FMedicare PIN