Provider Demographics
NPI:1528040193
Name:BANDARU, GARGEYI (MD)
Entity Type:Individual
Prefix:MRS
First Name:GARGEYI
Middle Name:
Last Name:BANDARU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GARGEYI
Other - Middle Name:
Other - Last Name:K
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1300 W TERRELL AVE STE K230
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2820
Mailing Address - Country:US
Mailing Address - Phone:817-250-4906
Mailing Address - Fax:817-250-1815
Practice Address - Street 1:1300 W TERRELL AVE STE K230
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2820
Practice Address - Country:US
Practice Address - Phone:817-250-4906
Practice Address - Fax:817-250-1815
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH086420208M00000X
TXQ2734207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX417144YKPWMedicare PIN
TX417144YKQLMedicare PIN