Healthcare Provider Details

I. General information

NPI: 1699701227
Provider Name (Legal Business Name): GORDON EARL BANKS PH.D.,M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 12/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 SE STRATUS AVE SUITE 304
MCMINNVILLE OR
97128-6255
US

IV. Provider business mailing address

2700 SE STRATUS AVE SUITE 304
MCMINNVILLE OR
97128-6255
US

V. Phone/Fax

Practice location:
  • Phone: 503-434-6090
  • Fax: 503-474-3306
Mailing address:
  • Phone: 503-434-6090
  • Fax: 503-474-3306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD21516
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: