Provider Demographics
NPI:1932127925
Name:BANKSTON, CHANDI D'LEE (DO)
Entity Type:Individual
Prefix:DR
First Name:CHANDI
Middle Name:D'LEE
Last Name:BANKSTON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 12TH ST
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-5810
Mailing Address - Country:US
Mailing Address - Phone:505-437-5716
Mailing Address - Fax:505-437-5733
Practice Address - Street 1:1315 12TH ST
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-5810
Practice Address - Country:US
Practice Address - Phone:505-437-5716
Practice Address - Fax:505-437-5733
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-1146-00207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM26422Medicaid
NMNM014B53OtherBLUE CROSS/BLUE SHIELD
NMN6766Medicaid
NMN6766Medicaid