Provider Demographics
NPI:1023010220
Name:BHANSALI, SANJAY A (MD)
Entity Type:Individual
Prefix:DR
First Name:SANJAY
Middle Name:A
Last Name:BHANSALI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5881 GLENRIDGE DR NE
Mailing Address - Street 2:STE 230
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-5301
Mailing Address - Country:US
Mailing Address - Phone:404-943-0170
Mailing Address - Fax:404-943-0171
Practice Address - Street 1:5881 GLENRIDGE DR NE
Practice Address - Street 2:STE 230
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-5301
Practice Address - Country:US
Practice Address - Phone:404-943-0170
Practice Address - Fax:404-943-0171
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA035006174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00476583DMedicaid
GAF02536Medicare UPIN
GA00476583DMedicaid