Healthcare Provider Details

I. General information

NPI: 1578755781
Provider Name (Legal Business Name): SHIPRA BANSAL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2007
Last Update Date: 11/01/2022
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2161 SAN JOAQUIN HILLS RD
NEWPORT BEACH CA
92660-6507
US

IV. Provider business mailing address

200 S MANCHESTER AVE STE 300
ORANGE CA
92868-3219
US

V. Phone/Fax

Practice location:
  • Phone: 949-386-5700
  • Fax:
Mailing address:
  • Phone: 714-456-2986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number40927
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA97868
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: