Healthcare Provider Details

I. General information

NPI: 1861827552
Provider Name (Legal Business Name): ANUSHA BANDLA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2013
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5325 FARAON ST
SAINT JOSEPH MO
64506-3488
US

IV. Provider business mailing address

36123 SCHOOLCRAFT RD
LIVONIA MI
48150-1216
US

V. Phone/Fax

Practice location:
  • Phone: 816-271-6406
  • Fax:
Mailing address:
  • Phone: 913-660-1616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2016032019
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberU3782
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number04-38829
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: