Basic Information
| Provider Information | |||||||||
| NPI: | 1578506820 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANDERA | ||||||||
| FirstName: | CHRISTINA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 ELLENFIELD ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029054513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014446779 | ||||||||
| FaxNumber: | 4014446912 | ||||||||
| Practice Location | |||||||||
| Address1: | 146 W RIVER ST FL 3 | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029042609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017937917 | ||||||||
| FaxNumber: | 4017937801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 06/28/2018 | ||||||||
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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 | 207VX0201X | 38024 | AZ | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology | 207VX0201X | MD11708 | RI | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology |
ID Information
| ID | Type | State | Issuer | Description | P00623760 | 01 | AZ | RAILROAD MEDICARE | OTHER | 86080015085054 C001 | 01 | AZ | TRICARE | OTHER | 313268 | 05 | AZ | MEDICAID |