Provider Demographics
NPI:1346275484
Name:BANSAL, SANJAY (MD)
Entity Type:Individual
Prefix:DR
First Name:SANJAY
Middle Name:
Last Name:BANSAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JAY
Other - Middle Name:
Other - Last Name:BANSAL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3540 MENDOCINO AVENUE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-3639
Mailing Address - Country:US
Mailing Address - Phone:707-522-6200
Mailing Address - Fax:707-522-6215
Practice Address - Street 1:3540 MENDOCINO AVENUE
Practice Address - Street 2:SUITE 200
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-3639
Practice Address - Country:US
Practice Address - Phone:707-522-6200
Practice Address - Fax:707-522-6215
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG66178207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF25128Medicare UPIN
CA11000231Medicare ID - Type Unspecified