Basic Information
| Provider Information | |||||||||
| NPI: | 1629265236 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOHN JEFFERYS BANDOLA, 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: | 09/27/2007 | ||||||||
| LastUpdateDate: | 03/23/2010 | ||||||||
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| AuthorizedOfficialLastName: | BANDOLA | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | JEFFERYS | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4017898543 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 5619 | RI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.