Basic Information
| Provider Information | |||||||||
| NPI: | 1750583746 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANDARU | ||||||||
| FirstName: | HIMABINDU | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3350 S 2940 E | ||||||||
| Address2: | PO BOX 9677 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841093159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8665007071 | ||||||||
| FaxNumber: | 8665007081 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 E 3900 S | ||||||||
| Address2: | SUITE 4B | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841241300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8665007071 | ||||||||
| FaxNumber: | 8665007081 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2007 | ||||||||
| LastUpdateDate: | 07/07/2014 | ||||||||
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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 | 207R00000X | 4301086019 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 0101243676 | VA | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 0101243676 | VA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | N8272 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 9065324-1205 | UT | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 7100049880 | 05 | KY | MEDICAID | 0G56008 | 01 | MI | BCBSM GROUP PIN | OTHER | 1107510812 | 01 | MI | BCBSM PIN | OTHER | 1750583746 | 05 | MI | MEDICAID |