Healthcare Provider Details

I. General information

NPI: 1558970194
Provider Name (Legal Business Name): TEJASWINI BANDARU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2020
Last Update Date: 10/23/2023
Certification Date: 10/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1114 6TH ST
MODESTO CA
95354-2203
US

IV. Provider business mailing address

737 W CHILDS AVE
MERCED CA
95341-6805
US

V. Phone/Fax

Practice location:
  • Phone: 209-576-2845
  • Fax: 209-576-8842
Mailing address:
  • Phone: 209-384-6481
  • Fax: 209-359-2045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number186281
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: