Provider Demographics
NPI:1790789725
Name:BANSAL, GIRIDHARI L (MD)
Entity Type:Individual
Prefix:
First Name:GIRIDHARI
Middle Name:L
Last Name:BANSAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:G
Other - Middle Name:L
Other - Last Name:BANSAL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1520 S DOBSON RD
Mailing Address - Street 2:STE 205
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-4726
Mailing Address - Country:US
Mailing Address - Phone:480-962-1808
Mailing Address - Fax:480-962-0738
Practice Address - Street 1:1520 S DOBSON RD
Practice Address - Street 2:STE 205
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-4726
Practice Address - Country:US
Practice Address - Phone:480-962-1808
Practice Address - Fax:480-962-0738
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-08
Last Update Date:2007-07-08
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-04-18
Provider Licenses
StateLicense IDTaxonomies
AZ6703208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
F-66947Medicare UPIN