Provider Demographics
NPI:1043396559
Name:BANTHIA, VISHAL (MD)
Entity Type:Individual
Prefix:
First Name:VISHAL
Middle Name:
Last Name:BANTHIA
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 1:39899 BALENTINE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:CA
Mailing Address - Zip Code:94560-5361
Mailing Address - Country:US
Mailing Address - Phone:800-453-1420
Mailing Address - Fax:800-453-1420
Practice Address - Street 1:2390 FARADAY AVE
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-7216
Practice Address - Country:US
Practice Address - Phone:858-909-0770
Practice Address - Fax:858-909-0880
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS8419207Y00000X
MI4301501683207Y00000X
CAA86814207YX0905X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1Y1840OtherMEDICARE UPIN
CA00A868140Medicaid
I12712Medicare UPIN