Provider Demographics
NPI:1962596700
Name:BANKS, UGOALA C (MD)
Entity type:Individual
Prefix:MR
First Name:UGOALA
Middle Name:C
Last Name:BANKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 316
Mailing Address - Street 2:
Mailing Address - City:KINGS MILLS
Mailing Address - State:OH
Mailing Address - Zip Code:45034-0316
Mailing Address - Country:US
Mailing Address - Phone:513-505-6309
Mailing Address - Fax:513-486-1868
Practice Address - Street 1:464 ATTLEBORO CT
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-2213
Practice Address - Country:US
Practice Address - Phone:513-505-6309
Practice Address - Fax:513-486-1868
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22449174400000X
OH127443207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810006842Medicaid
WA001908161OtherWV BLUE CROSS PIN #
WV520795508OtherTAX ID
P00345268OtherRAILROAD MEDICARE PIN
WVE95145Medicare UPIN
WV4193912Medicare PIN
WA001908161OtherWV BLUE CROSS PIN #