Provider Demographics
NPI:1265481311
Name:BANDA, MARY CONSOLATA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:CONSOLATA
Last Name:BANDA
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Gender:F
Credentials:MD
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Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:HARRINGTON PHYSICIAN SERVICES, INC.
Mailing Address - City:SOUTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01550-0040
Mailing Address - Country:US
Mailing Address - Phone:508-909-7799
Mailing Address - Fax:508-764-2432
Practice Address - Street 1:100 SOUTH ST
Practice Address - Street 2:HARRINGTON PHYSICIAN SERVICES, INC.
Practice Address - City:SOUTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01550-4051
Practice Address - Country:US
Practice Address - Phone:508-765-9771
Practice Address - Fax:508-909-7735
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2018-03-17
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Provider Licenses
StateLicense IDTaxonomies
MA75967207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ13190Medicaid
MAJ13190Medicaid
MAF44291Medicare UPIN