Provider Demographics
NPI:1316965643
Name:BANDERA, PETER BOHDAN (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:BOHDAN
Last Name:BANDERA
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 1:1 E BEACON LIGHT LN
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19013-4433
Mailing Address - Country:US
Mailing Address - Phone:610-532-2633
Mailing Address - Fax:610-532-7856
Practice Address - Street 1:217 KEDRON AVE
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:PA
Practice Address - Zip Code:19033-1310
Practice Address - Country:US
Practice Address - Phone:610-532-2633
Practice Address - Fax:610-532-7856
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD041244L208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012374630001Medicaid
PAE74888Medicare UPIN
PA0012374630001Medicaid