Provider Demographics
NPI:1700032331
Name:RAJ K. BANSAL, M.D., P.C.
Entity Type:Organization
Organization Name:RAJ K. BANSAL, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAJ
Authorized Official - Middle Name:K
Authorized Official - Last Name:BANSAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-739-5242
Mailing Address - Street 1:870 CRESTMARK DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LITHIA SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30122-2665
Mailing Address - Country:US
Mailing Address - Phone:770-739-5242
Mailing Address - Fax:
Practice Address - Street 1:870 CRESTMARK DR
Practice Address - Street 2:SUITE 201
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122-2665
Practice Address - Country:US
Practice Address - Phone:770-739-5242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-14
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048412174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty