Basic Information
| Provider Information | |||||||||
| NPI: | 1639129752 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANDLA | ||||||||
| FirstName: | PREETAM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25608 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841250608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063204476 | ||||||||
| FaxNumber: | 2065687043 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 17TH AVE FL A | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981225788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063864744 | ||||||||
| FaxNumber: | 2062151135 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 04/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD00046193 | WA | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0214X | MD00046193 | WA | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Pulmonology | 2080S0012X | MD00046193 | WA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Sleep Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1639129752 | 05 | WA | MEDICAID |