Provider Demographics
NPI:1639129752
Name:BANDLA, PREETAM (MD)
Entity Type:Individual
Prefix:DR
First Name:PREETAM
Middle Name:
Last Name:BANDLA
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:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:550 17TH AVE FL A
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-5788
Practice Address - Country:US
Practice Address - Phone:206-386-4744
Practice Address - Fax:206-215-1135
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00046193208000000X, 2080P0214X, 2080S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080S0012XAllopathic & Osteopathic PhysiciansPediatricsSleep Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1639129752Medicaid