Provider Demographics
NPI:1083615298
Name:BANDARI, BAHMAN (MD)
Entity Type:Individual
Prefix:
First Name:BAHMAN
Middle Name:
Last Name:BANDARI
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 1:12618 HAWTHORNE BLVD.
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-2325
Mailing Address - Country:US
Mailing Address - Phone:310-263-5700
Mailing Address - Fax:
Practice Address - Street 1:20911 EARL ST
Practice Address - Street 2:SUITE 440
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4352
Practice Address - Country:US
Practice Address - Phone:310-419-8585
Practice Address - Fax:310-419-8553
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA47790207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A477900Medicaid
F14003Medicare UPIN
CA00A477900Medicaid