Basic Information
| Provider Information | |||||||||
| NPI: | 1013087535 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANKS | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | LUNG-WONG | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5400 FRANTZ RD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | DUBLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430164144 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 THOMAS LN | ||||||||
| Address2: | SUITE 3G | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432141401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147882870 | ||||||||
| FaxNumber: | 6145330177 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 06/09/2016 | ||||||||
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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 | 208800000X | 35.082920 | OH | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 2639078 | 05 | OH | MEDICAID |