Healthcare Provider Details

I. General information

NPI: 1518499466
Provider Name (Legal Business Name): NIKETH BANDLA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2017
Last Update Date: 01/09/2025
Certification Date: 01/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2330 UTAH AVE STE 200
EL SEGUNDO CA
90245-4817
US

IV. Provider business mailing address

110 IRVING ST NW DEPARTMENT OF SURGERY
WASHINGTON DC
20010-3017
US

V. Phone/Fax

Practice location:
  • Phone: 281-766-0959
  • Fax:
Mailing address:
  • Phone: 202-877-3536
  • Fax: 202-877-3699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4301507188
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME163854
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: