Provider Demographics
NPI:1891905410
Name:BANKS, BRENDA LOUISE (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:LOUISE
Last Name:BANKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:BRENDA
Other - Middle Name:LOUIS
Other - Last Name:BANKS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:850 W EMMITT AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:WAVERLY
Mailing Address - State:OH
Mailing Address - Zip Code:45690-1092
Mailing Address - Country:US
Mailing Address - Phone:740-941-1902
Mailing Address - Fax:740-941-1913
Practice Address - Street 1:850 W EMMITT AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:WAVERLY
Practice Address - State:OH
Practice Address - Zip Code:45690-1092
Practice Address - Country:US
Practice Address - Phone:740-941-1902
Practice Address - Fax:740-941-1913
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35079787B174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2278646Medicaid
OHF12362Medicare UPIN