Provider Demographics
NPI:1124170097
Name:BANDUKWALA, QURESH Z (MD)
Entity type:Individual
Prefix:DR
First Name:QURESH
Middle Name:Z
Last Name:BANDUKWALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 SHORTER AVE NW
Mailing Address - Street 2:SUITE100
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-4268
Mailing Address - Country:US
Mailing Address - Phone:706-235-5722
Mailing Address - Fax:706-235-5728
Practice Address - Street 1:314 SHORTER AVE NW
Practice Address - Street 2:SUITE100
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-4268
Practice Address - Country:US
Practice Address - Phone:706-235-5722
Practice Address - Fax:706-235-5728
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0279592084P0800X, 2084P0804X
CAA391052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Not Answered2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00340458AMedicaid
GA00340458AMedicaid