Provider Demographics
NPI:1689863425
Name:BANSAL, MANISH (MD)
Entity Type:Individual
Prefix:
First Name:MANISH
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 1:6651 MAIN STREET
Mailing Address - Street 2:LEGACY TOWER
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030
Mailing Address - Country:US
Mailing Address - Phone:832-825-5600
Mailing Address - Fax:
Practice Address - Street 1:6651 MAIN STREET
Practice Address - Street 2:LEGACY TOWER E1920
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77005
Practice Address - Country:US
Practice Address - Phone:832-826-2789
Practice Address - Fax:832-826-4287
Is Sole Proprietor?:No
Enumeration Date:2007-10-17
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-435682080P0202X, 208000000X
TXP70662080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1026885970001Medicaid
OH3037556Medicaid
PA1026885970001Medicaid