Provider Demographics
NPI:1043392962
Name:JAGAN N. BANSAL, M.D., INC.
Entity Type:Organization
Organization Name:JAGAN N. BANSAL, M.D., INC.
Other - Org Name:COMPLETE FAMILY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JAGAN
Authorized Official - Middle Name:NATH
Authorized Official - Last Name:BANSAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-478-1101
Mailing Address - Street 1:5540 N FIGUEROA ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-4120
Mailing Address - Country:US
Mailing Address - Phone:323-478-1101
Mailing Address - Fax:323-255-2745
Practice Address - Street 1:5540 N FIGUEROA ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90042-4120
Practice Address - Country:US
Practice Address - Phone:323-478-1101
Practice Address - Fax:323-255-2745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0014481Medicaid
CAW15123AMedicare PIN
CAW15123Medicare UPIN