Provider Demographics
NPI:1518926724
Name:BANSAL, JAGDISH (MD)
Entity Type:Individual
Prefix:
First Name:JAGDISH
Middle Name:
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 1:15 QUAIL RUN
Mailing Address - Street 2:
Mailing Address - City:OLD WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11568-1044
Mailing Address - Country:US
Mailing Address - Phone:516-626-0429
Mailing Address - Fax:
Practice Address - Street 1:1807 RANDALL AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10473-3617
Practice Address - Country:US
Practice Address - Phone:718-842-3812
Practice Address - Fax:718-842-3828
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY111144207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00199106Medicaid
714031Medicare ID - Type Unspecified
B79054Medicare UPIN