Provider Demographics
NPI:1609830199
Name:BANDLER, MACK K (MD)
Entity Type:Individual
Prefix:DR
First Name:MACK
Middle Name:K
Last Name:BANDLER
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 1:842 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7134
Mailing Address - Country:US
Mailing Address - Phone:541-773-2493
Mailing Address - Fax:541-779-3027
Practice Address - Street 1:842 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7134
Practice Address - Country:US
Practice Address - Phone:541-773-2493
Practice Address - Fax:541-779-3027
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD148622085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR184556Medicaid
OR300020013Medicare PIN
OR184556Medicaid
OR00WCBCNJMedicare PIN