Healthcare Provider Details

I. General information

NPI: 1083699300
Provider Name (Legal Business Name): JEFFREY ALLAN BANKS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 08/22/2024
Certification Date: 08/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 POLIFKA DR BLDG 1042
SHAW AFB SC
29152-5100
US

IV. Provider business mailing address

420 POLIFKA DR BLDG 1042
SHAW AFB SC
29152-5100
US

V. Phone/Fax

Practice location:
  • Phone: 803-895-6356
  • Fax: 803-895-6040
Mailing address:
  • Phone: 803-895-6356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2010-01016
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number7284
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License NumberME85849
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: