Provider Demographics
NPI:1891793188
Name:BANKSTON, CECIL NOEL JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CECIL
Middle Name:NOEL
Last Name:BANKSTON
Suffix:JR
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 1:4841 WOODLAKE DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70817-1833
Mailing Address - Country:US
Mailing Address - Phone:225-753-7917
Mailing Address - Fax:
Practice Address - Street 1:4841 WOODLAKE DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70817-1833
Practice Address - Country:US
Practice Address - Phone:225-753-7917
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0116752085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1189596Medicaid
LAB60344Medicare UPIN
LA5C-117Medicare ID - Type Unspecified