Provider Demographics
NPI:1861476707
Name:BANKS, NICK D (OD)
Entity Type:Individual
Prefix:DR
First Name:NICK
Middle Name:D
Last Name:BANKS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2901 E ZION RD
Mailing Address - Street 2:STE 4
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-5007
Mailing Address - Country:US
Mailing Address - Phone:479-443-2025
Mailing Address - Fax:479-443-2032
Practice Address - Street 1:2901 E ZION RD
Practice Address - Street 2:STE 4
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-5007
Practice Address - Country:US
Practice Address - Phone:479-443-2025
Practice Address - Fax:479-443-2032
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-05
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2007152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR47968OtherARKANSAS BCBS
BA700418OtherHIGHMARK BCBS
410038411OtherRAILROAD MEDICARE
710814666OtherTID
AR106310722Medicaid
AR263122083OtherTAX ID
AR263122083OtherTAX ID
410038411OtherRAILROAD MEDICARE
T20150Medicare UPIN