Healthcare Provider Details

I. General information

NPI: 1831409218
Provider Name (Legal Business Name): TOLLESE H BANKETT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2010
Last Update Date: 10/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 EAST CHARLES STREET 2ND FLOOR
LAPLATA MD
20646-3946
US

IV. Provider business mailing address

404 EAST CHARLES STREET 2ND FLOOR
LAPLATA MD
20646-3946
US

V. Phone/Fax

Practice location:
  • Phone: 301-934-9391
  • Fax: 301-934-5439
Mailing address:
  • Phone: 301-934-9391
  • Fax: 301-934-5439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0043965
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: