Provider Demographics
NPI:1063473494
Name:BHANDARI, BAL RAJ (MD)
Entity Type:Individual
Prefix:DR
First Name:BAL
Middle Name:RAJ
Last Name:BHANDARI
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 1:616 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71220-5035
Mailing Address - Country:US
Mailing Address - Phone:318-283-2177
Mailing Address - Fax:318-283-2251
Practice Address - Street 1:616 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-5035
Practice Address - Country:US
Practice Address - Phone:318-283-2177
Practice Address - Fax:318-283-2251
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11414R174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1665836Medicaid
5W392Medicare ID - Type Unspecified
G15904Medicare UPIN