Provider Demographics
NPI:1376559336
Name:BANSAL, GIRRAJ KISHORE (MD)
Entity Type:Individual
Prefix:DR
First Name:GIRRAJ
Middle Name:KISHORE
Last Name:BANSAL
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 1:1649 BRICE ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-2796
Mailing Address - Country:US
Mailing Address - Phone:614-864-3434
Mailing Address - Fax:614-864-8811
Practice Address - Street 1:1649 BRICE ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-2796
Practice Address - Country:US
Practice Address - Phone:614-864-3434
Practice Address - Fax:614-864-8811
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH048549207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0536950Medicaid
OHA16858Medicare UPIN
OH0597523Medicare PIN
0597523Medicare PIN