Healthcare Provider Details

I. General information

NPI: 1821487612
Provider Name (Legal Business Name): NITIN BANSAL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2015
Last Update Date: 10/05/2021
Certification Date: 10/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 KENSINGTON AVE
BUFFALO NY
14215-1436
US

IV. Provider business mailing address

1515 KENSINGTON AVE
BUFFALO NY
14215-1436
US

V. Phone/Fax

Practice location:
  • Phone: 716-446-5900
  • Fax:
Mailing address:
  • Phone: 716-446-5900
  • Fax: 716-242-0225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number302887
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: