Provider Demographics
NPI:1023129491
Name:BANDOLA, JOHN JEFFERYS (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JEFFERYS
Last Name:BANDOLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 KENYON AVE
Mailing Address - Street 2:SUITE 326
Mailing Address - City:WAKEFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02879-4239
Mailing Address - Country:US
Mailing Address - Phone:401-789-8543
Mailing Address - Fax:401-782-8766
Practice Address - Street 1:70 KENYON AVE
Practice Address - Street 2:SUITE 326
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879-4239
Practice Address - Country:US
Practice Address - Phone:401-789-8543
Practice Address - Fax:401-782-8766
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRI5619207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1D9000094Medicaid
RI000196OtherRHODE ISLAND BLUE CHIP
RI0000000094OtherRHODE ISLAND BLUE CROSS AND BLUE SHIELD
RI0000000094OtherRHODE ISLAND BLUE CROSS AND BLUE SHIELD
RIC99021Medicare UPIN
RI000196OtherRHODE ISLAND BLUE CHIP