Provider Demographics
NPI:1922034321
Name:BANDI, SOMASEKHAR R (MD)
Entity Type:Individual
Prefix:DR
First Name:SOMASEKHAR
Middle Name:R
Last Name:BANDI
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 1:607 S NEW BALLAS RD
Mailing Address - Street 2:SUITE 3125
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8222
Mailing Address - Country:US
Mailing Address - Phone:314-353-1870
Mailing Address - Fax:314-353-1984
Practice Address - Street 1:607 S NEW BALLAS RD
Practice Address - Street 2:SUITE 3125
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8222
Practice Address - Country:US
Practice Address - Phone:314-353-1870
Practice Address - Fax:314-353-1984
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO105454207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1922034321Medicaid
MOP00684805OtherRAILROAD MEDICARE
MO209796622Medicaid
MO43-1823174OtherTAX IDENTIFICATION NUMBER
MOP00684805OtherRAILROAD MEDICARE
MOMA1377009Medicare PIN
MO902073094Medicare ID - Type UnspecifiedBANDI MEDICARE NUMBER