Healthcare Provider Details

I. General information

NPI: 1174512826
Provider Name (Legal Business Name): SANJIV BANSAL MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2705 WILLIAMSBRIDGE RD
BRONX NY
10469-4109
US

IV. Provider business mailing address

192 SHEPHERD LN
ROSLYN HEIGHTS NY
11577-2509
US

V. Phone/Fax

Practice location:
  • Phone: 718-515-9800
  • Fax: 718-231-7942
Mailing address:
  • Phone: 718-515-9800
  • Fax: 718-231-7942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number191686
License Number StateNY

VIII. Authorized Official

Name: SANJIV BANSAL
Title or Position: PRESIDENT
Credential: MD
Phone: 718-515-7800