Basic Information
| Provider Information | |||||||||
| NPI: | 1093778318 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANKSTON | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 215 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331334841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3054417179 | ||||||||
| FaxNumber: | 3054487134 | ||||||||
| Practice Location | |||||||||
| Address1: | 13001 SOUTHERN BLVD | ||||||||
| Address2: | PALM'S WEST HOSPITAL NICU | ||||||||
| City: | LOXAHATCHEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334702413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5618406220 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 2080N0001X | ME44216 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 062713500 | 05 | FL | MEDICAID |