Provider Demographics
NPI:1043696495
Name:BANDY, DOUG
Entity type:Individual
Prefix:
First Name:DOUG
Middle Name:
Last Name:BANDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 E IDAHO AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-2631
Mailing Address - Country:US
Mailing Address - Phone:208-917-7919
Mailing Address - Fax:208-917-7918
Practice Address - Street 1:33 E IDAHO AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2631
Practice Address - Country:US
Practice Address - Phone:208-917-7919
Practice Address - Fax:208-917-7918
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-08
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNOT REQUIRED253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care