Provider Demographics
NPI:1417149071
Name:BANSAL, VIDYA RAMAKRISHNAIAH (MD)
Entity Type:Individual
Prefix:
First Name:VIDYA
Middle Name:RAMAKRISHNAIAH
Last Name:BANSAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VIDYA
Other - Middle Name:B
Other - Last Name:RAMAKRISHNAIAH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:111 OTIS SMITH DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-8940
Mailing Address - Country:US
Mailing Address - Phone:931-553-6666
Mailing Address - Fax:
Practice Address - Street 1:111 OTIS SMITH DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043
Practice Address - Country:US
Practice Address - Phone:931-553-6666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-16
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35 090073208000000X
TN43833208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ035503Medicaid