Provider Demographics
NPI:1033643655
Name:BHANDARI, SUPRIYA (MD)
Entity Type:Individual
Prefix:
First Name:SUPRIYA
Middle Name:
Last Name:BHANDARI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 N CENTRAL AVE STE 1600
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2908
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1840 E BROADWAY RD
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-1614
Practice Address - Country:US
Practice Address - Phone:602-243-7277
Practice Address - Fax:480-927-1092
Is Sole Proprietor?:No
Enumeration Date:2017-04-20
Last Update Date:2021-09-30
Deactivation Date:2017-11-27
Deactivation Code:
Reactivation Date:2017-12-16
Provider Licenses
StateLicense IDTaxonomies
MI4301502133207RG0300X
390200000X
AZ62870207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program