Healthcare Provider Details

I. General information

NPI: 1790778009
Provider Name (Legal Business Name): MARK G BANDYK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 07/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3525 LAKELAND HILLS BLVD
LAKELAND FL
33805-1965
US

IV. Provider business mailing address

1324 LAKELAND HILLS BLVD ATTN: MEDICAL STAFF OFFICE
LAKELAND FL
33805-4543
US

V. Phone/Fax

Practice location:
  • Phone: 863-603-6565
  • Fax: 863-904-1961
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberME89653
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: