Provider Demographics
NPI:1013079037
Name:BANDUR, JOSEPH
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:BANDUR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17307 PAGONIA DR # 100
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-5932
Mailing Address - Country:US
Mailing Address - Phone:352-989-4941
Mailing Address - Fax:352-404-6971
Practice Address - Street 1:17307 PAGONIA DR # 100
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-5932
Practice Address - Country:US
Practice Address - Phone:352-989-4941
Practice Address - Fax:352-404-6971
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 7683111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008389400Medicaid
FLU84463Medicare UPIN
FL008389400Medicaid