Healthcare Provider Details

I. General information

NPI: 1205254083
Provider Name (Legal Business Name): DOMINIQUE JB BANDARI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2014
Last Update Date: 03/12/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 S. CLINTON AVE STE 360
ROCHESTER NY
14618
US

IV. Provider business mailing address

1815 S. CLINTON AVE STE 360
ROCHESTER NY
14618
US

V. Phone/Fax

Practice location:
  • Phone: 585-568-8330
  • Fax: 585-568-8327
Mailing address:
  • Phone: 585-568-8330
  • Fax: 585-568-8327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD460458
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: