Provider Demographics
NPI:1003978669
Name:MIMI G BANSAL, MD
Entity Type:Organization
Organization Name:MIMI G BANSAL, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIMI
Authorized Official - Middle Name:G
Authorized Official - Last Name:BANSAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-352-2700
Mailing Address - Street 1:2 POLO DR
Mailing Address - Street 2:
Mailing Address - City:OLD WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11568-1043
Mailing Address - Country:US
Mailing Address - Phone:516-352-2700
Mailing Address - Fax:516-437-6904
Practice Address - Street 1:2001 MARCUS AVE
Practice Address - Street 2:SUITE N218
Practice Address - City:LAKE SUCCESS
Practice Address - State:NY
Practice Address - Zip Code:11042
Practice Address - Country:US
Practice Address - Phone:516-352-2700
Practice Address - Fax:516-437-6904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2122661207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty