Provider Demographics
NPI:1205254083
Name:BANDARI, DOMINIQUE JB (MD)
Entity type:Individual
Prefix:MRS
First Name:DOMINIQUE
Middle Name:JB
Last Name:BANDARI
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 S. CLINTON AVE STE 360
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618
Mailing Address - Country:US
Mailing Address - Phone:585-568-8330
Mailing Address - Fax:585-568-8327
Practice Address - Street 1:1815 S. CLINTON AVE STE 360
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618
Practice Address - Country:US
Practice Address - Phone:585-568-8330
Practice Address - Fax:585-568-8327
Is Sole Proprietor?:No
Enumeration Date:2014-03-31
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD460458208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY60851629Medicaid