Basic Information
| Provider Information | |||||||||
| NPI: | 1205254083 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANDARI | ||||||||
| FirstName: | DOMINIQUE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11279 PERRY HWY STE 450 | ||||||||
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| City: | WEXFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150909303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7249331100 | ||||||||
| FaxNumber: | 7249331160 | ||||||||
| Practice Location | |||||||||
| Address1: | 140 WAYLAND SMITH DR | ||||||||
| Address2: | |||||||||
| City: | UNIONTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 154012677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7244379854 | ||||||||
| FaxNumber: | 7244378305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2014 | ||||||||
| LastUpdateDate: | 12/13/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD460458 | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.