MEDICARE: DIVYA BANSAL D.O.

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	390200000X	Student in an Organized Health Care Education/Training Program	L.4102R	AL

General Provider Information

NPI Number	:	1619369774
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIVYA BANSAL D.O.

Provider Business Mailing Address
First Line	:	4371 NARROW LANE RD STE 100
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36116-2975
Country	:	US
Telephone Number	:	334-613-3680
Fax Number	:	334-613-3685

Provider Business Practice Location Address
First Line	:	4371 NARROW LANE RD STE 100
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36116-2975
Country	:	US
Telephone Number	:	334-613-3680
Fax Number	:	334-613-3685

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

Provider Enumeration Date	:	02/26/2015
Last Update Date	:	02/26/2015

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