Healthcare Provider Details

I. General information

NPI: 1598732851
Provider Name (Legal Business Name): BENJAMIN BALTAZAR BANDONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 DIVISION STREET
BALTIMORE MD
21217
US

IV. Provider business mailing address

308 PATLEIGH ROAD
CATONSVILLE MD
21228-5630
US

V. Phone/Fax

Practice location:
  • Phone: 410-383-8300
  • Fax: 410-728-4412
Mailing address:
  • Phone: 410-788-8875
  • Fax: 410-747-4237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0016938
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: