Provider Demographics
NPI:1720030109
Name:BANDUKWALA, IBREZ R (MD)
Entity Type:Individual
Prefix:MR
First Name:IBREZ
Middle Name:R
Last Name:BANDUKWALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6600 PEACHTREE DUNWOODY RD STE 325
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-6773
Mailing Address - Country:US
Mailing Address - Phone:404-876-1906
Mailing Address - Fax:404-215-9222
Practice Address - Street 1:1110 W PEACHTREE ST NW STE 1100
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309
Practice Address - Country:US
Practice Address - Phone:404-892-2131
Practice Address - Fax:404-215-9222
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA46036207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAH14387Medicare UPIN