Provider Demographics
NPI:1760457659
Name:BANSAL, RADHEY SHIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:RADHEY
Middle Name:SHIAM
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 1:1230 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:DELANO
Mailing Address - State:CA
Mailing Address - Zip Code:93215-2204
Mailing Address - Country:US
Mailing Address - Phone:661-725-7793
Mailing Address - Fax:661-725-0595
Practice Address - Street 1:1230 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:DELANO
Practice Address - State:CA
Practice Address - Zip Code:93215
Practice Address - Country:US
Practice Address - Phone:661-725-7793
Practice Address - Fax:661-725-0595
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-22
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA39293207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ17879ZMedicaid
CAZZZ17879ZMedicare ID - Type Unspecified
CAZZZ17879ZMedicaid