Provider Demographics
NPI:1871709147
Name:BANDOW, GRACE DOLORES (MD)
Entity type:Individual
Prefix:DR
First Name:GRACE
Middle Name:DOLORES
Last Name:BANDOW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 CORPORATE DR
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-6211
Mailing Address - Country:US
Mailing Address - Phone:203-538-5682
Mailing Address - Fax:203-538-5685
Practice Address - Street 1:4 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-6211
Practice Address - Country:US
Practice Address - Phone:203-538-5682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT47948207ND0900X, 207N00000X
RIMD13871207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI314006OtherNEIGHBORHOOD HEALTH PLAN OF RI
RIC14050OtherRAILROAD MEDICARE PTAN
RI1871709147OtherBLUE CROSS BLUE SHIELD
RIAA264676OtherHARVARD PILGRIM
RIGB89470Medicaid
RI002799901Medicare PIN