Healthcare Provider Details

I. General information

NPI: 1033643655
Provider Name (Legal Business Name): SUPRIYA BHANDARI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2017
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date: 11/27/2017
Reactivation Date: 12/16/2017

III. Provider practice location address

1300 S COUNTRY CLUB DR STE 3
MESA AZ
85210-5162
US

IV. Provider business mailing address

2901 N CENTRAL AVE ST 160
PHOENIX AZ
85012-2700
US

V. Phone/Fax

Practice location:
  • Phone: 480-827-5500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number62870
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number4301502133
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: