Basic Information
| Provider Information | |||||||||
| NPI: | 1659772069 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANKS | ||||||||
| FirstName: | MATTHEW | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1219 WALTER REED RD | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283044437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106153350 | ||||||||
| FaxNumber: | 9103216253 | ||||||||
| Practice Location | |||||||||
| Address1: | 11100 EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441061716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168441000 | ||||||||
| FaxNumber: | 2169830792 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2014 | ||||||||
| LastUpdateDate: | 07/25/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2084N0400X | 2019-01508 | NC | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.