Provider Demographics
NPI:1215538061
Name:BANSAL, NIKHIL DEEP
Entity Type:Individual
Prefix:
First Name:NIKHIL
Middle Name:DEEP
Last Name:BANSAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:485 ROUTE 1 SOUTH
Mailing Address - Street 2:
Mailing Address - City:ISELIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08830
Mailing Address - Country:US
Mailing Address - Phone:732-750-0400
Mailing Address - Fax:
Practice Address - Street 1:100 PRESIDENTIAL BLVD STE 200
Practice Address - Street 2:
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-1108
Practice Address - Country:US
Practice Address - Phone:484-434-2700
Practice Address - Fax:610-660-0419
Is Sole Proprietor?:No
Enumeration Date:2020-11-06
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV009223-01152W00000X
PAOEG003834152W00000X
NJ27OM00168500152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist