Provider Demographics
NPI:1033177936
Name:BANSAL, RAJ KUMARI (MD)
Entity Type:Individual
Prefix:
First Name:RAJ
Middle Name:KUMARI
Last Name:BANSAL
Suffix:
Gender:F
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:PO BOX 5246
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06610-0246
Mailing Address - Country:US
Mailing Address - Phone:203-384-3873
Mailing Address - Fax:
Practice Address - Street 1:226 MILL HILL AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610-2811
Practice Address - Country:US
Practice Address - Phone:203-384-3873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0233032084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001233030Medicaid