Healthcare Provider Details

I. General information

NPI: 1811970486
Provider Name (Legal Business Name): PRIYA J BANSAL M.D.,
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2005
Last Update Date: 02/20/2023
Certification Date: 02/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2435 DEAN ST UNIT C
SAINT CHARLES IL
60175-4827
US

IV. Provider business mailing address

1187 CLEANDER CT
NAPERVILLE IL
60540-7352
US

V. Phone/Fax

Practice location:
  • Phone: 630-584-6127
  • Fax: 630-584-6070
Mailing address:
  • Phone: 630-247-4304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number036103919
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number036103919
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number036103919
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number036103919
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: