Provider Demographics
NPI:1578659322
Name:BANSAL, JATINDER (OD)
Entity Type:Individual
Prefix:DR
First Name:JATINDER
Middle Name:
Last Name:BANSAL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 COLLEGE ST SE
Mailing Address - Street 2:STE C
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-1014
Mailing Address - Country:US
Mailing Address - Phone:360-923-4330
Mailing Address - Fax:360-456-3894
Practice Address - Street 1:1200 STATION DR
Practice Address - Street 2:#150
Practice Address - City:DUPONT
Practice Address - State:WA
Practice Address - Zip Code:98327-9804
Practice Address - Country:US
Practice Address - Phone:253-912-2020
Practice Address - Fax:253-579-1153
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD4053152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2012279Medicaid
WAG8901515Medicare PIN