1790786846 NPI number — DR. DHANANJAY DEODATTA BENDRE MD

Table of content: DR. DHANANJAY DEODATTA BENDRE MD (NPI 1790786846)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790786846 NPI number — DR. DHANANJAY DEODATTA BENDRE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENDRE
Provider First Name:
DHANANJAY
Provider Middle Name:
DEODATTA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1790786846
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/28/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1775 ONE HEALING PLACE
Provider Second Line Business Mailing Address:
RADIATION ONCOLOGY SPECIALISTS
Provider Business Mailing Address City Name:
TALLAHASSEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-431-5255
Provider Business Mailing Address Fax Number:
850-431-6039

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1775 ONE HEALING PLACE
Provider Second Line Business Practice Location Address:
RADIATION ONCOLOGY SPECIALISTS
Provider Business Practice Location Address City Name:
TALLAHASSEE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-431-5255
Provider Business Practice Location Address Fax Number:
850-431-6039
Provider Enumeration Date:
08/10/2005

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: 2085R0001X , with the licence number:  036104478 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0001X , with the licence number: ME118833 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 036104478 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010664600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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