Provider Demographics
NPI:1235318023
Name:CHANDI BANKSTON, D.O.
Entity type:Organization
Organization Name:CHANDI BANKSTON, D.O.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:BANKSTON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:505-437-5716
Mailing Address - Street 1:1315 12TH ST
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-5810
Mailing Address - Country:US
Mailing Address - Phone:505-437-5716
Mailing Address - Fax:505-437-5733
Practice Address - Street 1:1315 12TH ST
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-5810
Practice Address - Country:US
Practice Address - Phone:505-437-5716
Practice Address - Fax:505-437-5733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-1146-00207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H97480Medicare UPIN