Provider Demographics
NPI:1841379138
Name:BANSAL, OM PRAKASH (MD)
Entity Type:Individual
Prefix:DR
First Name:OM
Middle Name:PRAKASH
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 1:3 SUTTER AVENUE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11212
Mailing Address - Country:US
Mailing Address - Phone:718-604-7242
Mailing Address - Fax:718-467-1782
Practice Address - Street 1:3 SUTTER AVENUE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212
Practice Address - Country:US
Practice Address - Phone:718-604-7242
Practice Address - Fax:718-467-1782
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY156961207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A60397Medicare UPIN
NY09D881Medicare ID - Type Unspecified
NY00806079Medicare ID - Type Unspecified