=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932102456
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAGAN BANSAL M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2005
-----------------------------------------------------
Last Update Date | 09/15/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5540 N FIGUEROA ST
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90042-4120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-478-1101
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5540 N FIGUEROA ST
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90042-4120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-478-1101
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number | A34128
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------