Provider Demographics
NPI:1427205681
Name:BANDERA, BRADLEY CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:CHARLES
Last Name:BANDERA
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 1:2200 SANTA MONICA BLVD
Mailing Address - Street 2:JOHN WAYNE CANCER INSTITUTE
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404
Mailing Address - Country:US
Mailing Address - Phone:310-449-5249
Mailing Address - Fax:
Practice Address - Street 1:2200 SANTA MONICA BLVD
Practice Address - Street 2:JOHN WAYNE CANCER INSTITUTE
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404
Practice Address - Country:US
Practice Address - Phone:310-449-5249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-19
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA61600390200000X, 208600000X
CAA1357982086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201124040AMedicaid
MO1427205681Medicaid
OK200619660AMedicaid
MOMA2082517Medicare PIN