Healthcare Provider Details

I. General information

NPI: 1871709147
Provider Name (Legal Business Name): GRACE DOLORES BANDOW M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 04/20/2023
Certification Date: 04/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 CORPORATE DR
SHELTON CT
06484-6211
US

IV. Provider business mailing address

4 CORPORATE DR
SHELTON CT
06484-6211
US

V. Phone/Fax

Practice location:
  • Phone: 203-538-5682
  • Fax:
Mailing address:
  • Phone: 203-538-5682
  • Fax: 203-538-5685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number47948
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number47948
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: