Provider Demographics
NPI:1568453298
Name:BANDEALY, MALIK T (MD)
Entity Type:Individual
Prefix:
First Name:MALIK
Middle Name:T
Last Name:BANDEALY
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 1:6811 118TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-8420
Mailing Address - Country:US
Mailing Address - Phone:262-857-5750
Mailing Address - Fax:
Practice Address - Street 1:6811 118TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-8420
Practice Address - Country:US
Practice Address - Phone:262-857-5750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38678207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32360000Medicaid
WI019940460Medicare PIN
G48380Medicare UPIN
000132080Medicare ID - Type Unspecified
001301300Medicare ID - Type Unspecified
WI462364694Medicare PIN