Healthcare Provider Details

I. General information

NPI: 1790789725
Provider Name (Legal Business Name): GIRIDHARI L BANSAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

Provider Other Name: G L BANSAL MD

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date: 03/21/2006
Reactivation Date: 04/18/2006

III. Provider practice location address

1520 S DOBSON RD STE 205
MESA AZ
85202-4726
US

IV. Provider business mailing address

1520 S DOBSON RD STE 205
MESA AZ
85202-4726
US

V. Phone/Fax

Practice location:
  • Phone: 480-962-1808
  • Fax: 480-962-0738
Mailing address:
  • Phone: 480-962-1808
  • Fax: 480-962-0738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number6703
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: