Healthcare Provider Details

I. General information

NPI: 1518926724
Provider Name (Legal Business Name): JAGDISH BANSAL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 10/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1807 RANDALL AVE
BRONX NY
10473-3617
US

IV. Provider business mailing address

15 QUAIL RUN
OLD WESTBURY NY
11568-1044
US

V. Phone/Fax

Practice location:
  • Phone: 718-842-3812
  • Fax: 718-842-3828
Mailing address:
  • Phone: 516-626-0429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number111144
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: