Provider Demographics
NPI:1750401998
Name:BANDT, ANYA ELIZABETH (MD)
Entity type:Individual
Prefix:DR
First Name:ANYA
Middle Name:ELIZABETH
Last Name:BANDT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANYA
Other - Middle Name:E
Other - Last Name:LANDECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1310 COMMERCE STREET
Mailing Address - Street 2:SUITE B
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-1469
Mailing Address - Country:US
Mailing Address - Phone:707-778-7862
Mailing Address - Fax:707-778-0969
Practice Address - Street 1:1660 SECOND STREET
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2707
Practice Address - Country:US
Practice Address - Phone:415-259-0131
Practice Address - Fax:415-259-0133
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65186207N00000X, 207ND0101X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
BS808ZMedicare PIN