Provider Demographics
NPI:1528064078
Name:BANDA, MICHAEL A (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:BANDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1202 LOUISIANA AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-3910
Mailing Address - Country:US
Mailing Address - Phone:318-212-8951
Mailing Address - Fax:318-212-6752
Practice Address - Street 1:2400 HOSPITAL DR
Practice Address - Street 2:STE. 250
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2385
Practice Address - Country:US
Practice Address - Phone:318-746-4460
Practice Address - Fax:318-746-3389
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.09177R208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1493651Medicaid
LA5DE54Medicare PIN
LA1493651Medicaid
LA5A613Medicare PIN
LA5A613DE54Medicare PIN