Provider Demographics
NPI:1104017888
Name:BANDEL, JACK WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:WILLIAM
Last Name:BANDEL
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 1:20818 W DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33180-1147
Mailing Address - Country:US
Mailing Address - Phone:305-933-3035
Mailing Address - Fax:305-933-8035
Practice Address - Street 1:20818 W DIXIE HWY
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33180-1147
Practice Address - Country:US
Practice Address - Phone:305-933-3035
Practice Address - Fax:305-933-8035
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-07
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME681332080N0001X, 2080P0202X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104831200Medicaid