1023129491 NPI number — DR. JOHN JEFFERYS BANDOLA M.D.

Table of content: DR. JOHN JEFFERYS BANDOLA M.D. (NPI 1023129491)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023129491 NPI number — DR. JOHN JEFFERYS BANDOLA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BANDOLA
Provider First Name:
JOHN
Provider Middle Name:
JEFFERYS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023129491
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/18/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
70 KENYON AVE
Provider Second Line Business Mailing Address:
SUITE 326
Provider Business Mailing Address City Name:
WAKEFIELD
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02879-4239
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-789-8543
Provider Business Mailing Address Fax Number:
401-782-8766

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
70 KENYON AVE
Provider Second Line Business Practice Location Address:
SUITE 326
Provider Business Practice Location Address City Name:
WAKEFIELD
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02879-4239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-789-8543
Provider Business Practice Location Address Fax Number:
401-782-8766
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  RI5619 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1D9000094 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000196 . This is a "RHODE ISLAND BLUE CHIP" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 0000000094 . This is a "RHODE ISLAND BLUE CROSS AND BLUE SHIELD" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".




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