Provider Demographics
NPI:1750583746
Name:BANDARU, HIMABINDU (MD)
Entity type:Individual
Prefix:
First Name:HIMABINDU
Middle Name:
Last Name:BANDARU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3350 S 2940 E
Mailing Address - Street 2:PO BOX 9677
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-3159
Mailing Address - Country:US
Mailing Address - Phone:866-500-7071
Mailing Address - Fax:866-500-7081
Practice Address - Street 1:1200 E 3900 S
Practice Address - Street 2:SUITE 4B
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1300
Practice Address - Country:US
Practice Address - Phone:866-500-7071
Practice Address - Fax:866-500-7081
Is Sole Proprietor?:No
Enumeration Date:2007-06-03
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301086019207R00000X
VA0101243676208M00000X, 207R00000X
TXN8272207R00000X
UT9065324-1205208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100049880Medicaid
MI0G56008OtherBCBSM GROUP PIN
MI1107510812OtherBCBSM PIN
MI1750583746Medicaid
MI1750583746Medicaid
KY7100049880Medicaid
MIG56008163Medicare PIN