Healthcare Provider Details

I. General information

NPI: 1811980113
Provider Name (Legal Business Name): ABDALLA ZACKARIA BANDAK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4920 MACCORKLE AVE SE
CHARLESTON WV
25304-2052
US

IV. Provider business mailing address

4920 MACCORKLE AVE SE
CHARLESTON WV
25304-2052
US

V. Phone/Fax

Practice location:
  • Phone: 304-741-5510
  • Fax:
Mailing address:
  • Phone: 304-741-5510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number21839
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: