Provider Demographics
NPI:1396364527
Name:BANDARU, SAI SAMYUKTHA
Entity Type:Individual
Prefix:
First Name:SAI SAMYUKTHA
Middle Name:
Last Name:BANDARU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22301 FOSTER WINTER DRIVE PROVIDENCE CANCER CENTER,
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-3707
Mailing Address - Country:US
Mailing Address - Phone:248-849-3541
Mailing Address - Fax:248-849-2899
Practice Address - Street 1:22301 FOSTER WINTER DRIVE PROVIDENCE CANCER CENTER,
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3707
Practice Address - Country:US
Practice Address - Phone:248-849-3541
Practice Address - Fax:248-849-2899
Is Sole Proprietor?:No
Enumeration Date:2020-04-08
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4351050876207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology