Provider Demographics
NPI:1568563567
Name:BANSAL, MIMI G X (MD)
Entity Type:Individual
Prefix:DR
First Name:MIMI
Middle Name:G
Last Name:BANSAL
Suffix:X
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 POLO DR
Mailing Address - Street 2:
Mailing Address - City:OLD WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11568-1043
Mailing Address - Country:US
Mailing Address - Phone:516-352-2700
Mailing Address - Fax:516-437-6904
Practice Address - Street 1:2001 MARCUS AVE
Practice Address - Street 2:SUITE N218
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1011
Practice Address - Country:US
Practice Address - Phone:516-352-2700
Practice Address - Fax:516-437-6904
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY212266-1207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3C2836OtherHEALTHNET
NYP1916938OtherOXFORD
NY3K8631OtherEMPIRE BCBS
NY2529062OtherAETNA
NY09U951Medicare ID - Type Unspecified
NY3K8631OtherEMPIRE BCBS