Provider Demographics
NPI:1770586885
Name:DANDADE, PRITAM BAJIRAO (MD)
Entity type:Individual
Prefix:MR
First Name:PRITAM
Middle Name:BAJIRAO
Last Name:DANDADE
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 1:7 MINA PERDIDA ST
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-2203
Mailing Address - Country:US
Mailing Address - Phone:915-544-1819
Mailing Address - Fax:915-544-1709
Practice Address - Street 1:615 E SCHUSTER AVE STE 8
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-4360
Practice Address - Country:US
Practice Address - Phone:915-545-1707
Practice Address - Fax:915-544-1709
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE0437174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX099671202Medicaid
TX00P381Medicare ID - Type Unspecified
TX099671202Medicaid