Basic Information
| Provider Information | |||||||||
| NPI: | 1023129491 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BANDOLA | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | JEFFERYS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 70 KENYON AVE | ||||||||
| Address2: | SUITE 326 | ||||||||
| City: | WAKEFIELD | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028794239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017898543 | ||||||||
| FaxNumber: | 4017828766 | ||||||||
| Practice Location | |||||||||
| Address1: | 70 KENYON AVE | ||||||||
| Address2: | SUITE 326 | ||||||||
| City: | WAKEFIELD | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028794239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017898543 | ||||||||
| FaxNumber: | 4017828766 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 03/18/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | RI5619 | RI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1D9000094 | 05 | RI | MEDICAID | 000196 | 01 | RI | RHODE ISLAND BLUE CHIP | OTHER | 0000000094 | 01 | RI | RHODE ISLAND BLUE CROSS AND BLUE SHIELD | OTHER |