Healthcare Provider Details

I. General information

NPI: 1427209725
Provider Name (Legal Business Name): SAMIKSHA BANSAL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SAMIKSHA SINGHAL M.D.

II. Dates (important events)

Enumeration Date: 10/06/2008
Last Update Date: 07/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 JOHNSON FY RD NE
ATLANTA GA
30342-1605
US

IV. Provider business mailing address

6 DOGWOOD LN
SAINT LOUIS MO
63124-1217
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-7819
  • Fax:
Mailing address:
  • Phone: 315-406-7836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number2015010142
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: