Provider Demographics
NPI:1689945776
Name:BANSAL, ERIC J (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:J
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 1:1701 E CESAR E CHAVEZ AVE STE 125
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-2445
Mailing Address - Country:US
Mailing Address - Phone:323-441-1122
Mailing Address - Fax:323-441-1173
Practice Address - Street 1:1701 E CESAR E CHAVEZ AVE STE 125
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-2445
Practice Address - Country:US
Practice Address - Phone:323-441-1122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-20
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA122292207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA113889OtherSID # 113889