Healthcare Provider Details

I. General information

NPI: 1104336460
Provider Name (Legal Business Name): HARIKRISHNA BANDLA MBBS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2017
Last Update Date: 03/07/2023
Certification Date: 01/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 JACKSON ST
MONROE LA
71201-7407
US

IV. Provider business mailing address

309 JACKSON ST
MONROE LA
71201-7407
US

V. Phone/Fax

Practice location:
  • Phone: 318-966-4541
  • Fax: 318-966-4543
Mailing address:
  • Phone: 318-966-4541
  • Fax: 318-966-4543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number324405
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: