Healthcare Provider Details

I. General information

NPI: 1174665756
Provider Name (Legal Business Name): VIJAYA BANSAL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 04/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1617 N. CALIFORNIA ST. SUITE 2A
STOCKTON CA
95204
US

IV. Provider business mailing address

P.O. BOX 1090
LODI CA
95241-1090
US

V. Phone/Fax

Practice location:
  • Phone: 209-466-8546
  • Fax: 209-466-3335
Mailing address:
  • Phone: 209-334-1800
  • Fax: 209-334-1430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License NumberA69278
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA69278
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA69278
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: