Provider Demographics
NPI:1598732851
Name:BANDONG, BENJAMIN BALTAZAR (MD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:BALTAZAR
Last Name:BANDONG
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 1:308 PATLEIGH ROAD
Mailing Address - Street 2:
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-5630
Mailing Address - Country:US
Mailing Address - Phone:410-788-8875
Mailing Address - Fax:410-747-4237
Practice Address - Street 1:1501 DIVISION STREET
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21217
Practice Address - Country:US
Practice Address - Phone:410-383-8300
Practice Address - Fax:410-728-4412
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0016938207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AB6155825OtherBHDD
MDD0016938OtherLICENSE
AB6155825OtherBHDD