MEDICARE: AMY P BANSAL M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Y00000X	Otolaryngology Physician	MD-47306	IA
2	207YX0007X	Plastic Surgery within the Head & Neck (Otolaryngology) Physician	A167507	CA
3	207Y00000X	Otolaryngology Physician	A167507	CA

General Provider Information

NPI Number	:	1437569613
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY P BANSAL M.D.

Provider Business Mailing Address
First Line	:	PO BOX 1475
Second Line	:
City	:	WALNUT
State	:	CA
Zip	:	91788-1475
Country	:	US
Telephone Number	:	909-973-0150
Fax Number	:

Provider Business Practice Location Address
First Line	:	2080 CENTURY PARK E STE 710
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90067-2010
Country	:	US
Telephone Number	:	310-715-3237
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/28/2014
Last Update Date	:	03/02/2022

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