Provider Demographics
NPI:1043423874
Name:BANGALORE, SAMIR (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMIR
Middle Name:
Last Name:BANGALORE
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 100744
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-2424
Mailing Address - Country:US
Mailing Address - Phone:702-961-7310
Mailing Address - Fax:844-231-4920
Practice Address - Street 1:3201 S MARYLAND PKWY STE 220
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-2424
Practice Address - Country:US
Practice Address - Phone:702-961-7310
Practice Address - Fax:844-231-4920
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL361157162084N0400X
NV124622084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1043423874Medicaid
AZ299316Medicaid
NV1043423874Medicaid
CA1043423874Medicaid
NVCR343ZMedicare PIN
P00473972Medicare PIN
NV1043423874Medicaid
NVV105684Medicare PIN