Provider Demographics
NPI:1689968943
Name:BANKURU, SATISH JAGAN MOHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SATISH
Middle Name:JAGAN MOHAN
Last Name:BANKURU
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 1:1750 THOMPSON RD
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2100
Mailing Address - Country:US
Mailing Address - Phone:541-269-0333
Mailing Address - Fax:
Practice Address - Street 1:1750 THOMPSON RD
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2100
Practice Address - Country:US
Practice Address - Phone:541-269-0333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-04
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301098724207R00000X
ORMD165899207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine