Provider Demographics
NPI:1114908209
Name:BANSAL, ASHOK KUMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:ASHOK
Middle Name:KUMAR
Last Name:BANSAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ASHOK
Other - Middle Name:
Other - Last Name:KUMAR-BANSAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:26206 W 12 MILE RD
Mailing Address - Street 2:STE 202
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1754
Mailing Address - Country:US
Mailing Address - Phone:248-827-7612
Mailing Address - Fax:248-827-7615
Practice Address - Street 1:26206 W 12 MILE RD
Practice Address - Street 2:STE 202
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1754
Practice Address - Country:US
Practice Address - Phone:248-827-7612
Practice Address - Fax:248-827-7615
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301057441207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3150549Medicaid
F63583Medicare UPIN
0829821Medicare ID - Type Unspecified