Basic Information
| Provider Information | |||||||||
| NPI: | 1518499466 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANDLA | ||||||||
| FirstName: | NIKETH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 IRVING ST NW | ||||||||
| Address2: | DEPARTMENT OF SURGERY | ||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200103017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2028773536 | ||||||||
| FaxNumber: | 2028773699 | ||||||||
| Practice Location | |||||||||
| Address1: | 2799 W GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482022608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006536568 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2017 | ||||||||
| LastUpdateDate: | 06/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2085R0202X | 4301507188 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.