Healthcare Provider Details

I. General information

NPI: 1225502883
Provider Name (Legal Business Name): ROBERT BANKS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2019
Last Update Date: 01/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6014 STODDARD CT APT P2
ALEXANDRIA VA
22315-5607
US

IV. Provider business mailing address

6014 STODDARD CT APT P2
ALEXANDRIA VA
22315-5607
US

V. Phone/Fax

Practice location:
  • Phone: 240-993-6207
  • Fax:
Mailing address:
  • Phone: 240-993-6207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number2081S0010X
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: