Basic Information
| Provider Information | |||||||||
| NPI: | 1629298740 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANKS | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | ANTHONY | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6427 W 84TH STREET | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3106410101 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1300 N VERMONT AVENUE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2134133000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2007 | ||||||||
| LastUpdateDate: | 09/03/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A52604 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A52608 | 05 | CA | MEDICAID |