=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720364227
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDICAL AND AESTHETIC DERMATOLOGY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2011
-----------------------------------------------------
Last Update Date | 06/29/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9256 BENDIX RD STE 200A
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21045-1848
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-593-5829
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9256 BENDIX RD STE 200A
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21045-1848
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CHERYL BANSAL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 302-593-5829
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | D72260
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------