Healthcare Provider Details

I. General information

NPI: 1205366630
Provider Name (Legal Business Name): PREETI BANGA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PREETI NAGPAL MD

II. Dates (important events)

Enumeration Date: 06/18/2017
Last Update Date: 10/16/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3264 N EVERGREEN DR NE
GRAND RAPIDS MI
49525-9746
US

IV. Provider business mailing address

3264 N EVERGREEN DR NE
GRAND RAPIDS MI
49525-9746
US

V. Phone/Fax

Practice location:
  • Phone: 616-363-7272
  • Fax: 616-361-5828
Mailing address:
  • Phone: 616-363-7272
  • Fax: 616-361-5828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4301509096
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: