Basic Information
| Provider Information | |||||||||
| NPI: | 1871677856 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANKS | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | W. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1800 HARRISON ST FL 7 | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946123429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5106256262 | ||||||||
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| Practice Location | |||||||||
| Address1: | 99 MONTECILLO RD | ||||||||
| Address2: | |||||||||
| City: | SAN RAFAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949033308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154442000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 208600000X | C39199 | CA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00C391990 | 05 | CA | MEDICAID |