Provider Demographics
NPI:1467874800
Name:BANSAL, MANU
Entity Type:Individual
Prefix:
First Name:MANU
Middle Name:
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:PO BOX 432
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41502-0432
Mailing Address - Country:US
Mailing Address - Phone:606-218-6280
Mailing Address - Fax:
Practice Address - Street 1:911 BY PASS ROAD
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-1689
Practice Address - Country:US
Practice Address - Phone:606-218-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-18
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY48158207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100366220Medicaid
KYK157480Medicare PIN