Provider Demographics
NPI:1861688848
Name:BANSAL, SANJIV (MD)
Entity Type:Individual
Prefix:
First Name:SANJIV
Middle Name:
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 1:192 SHEPHERD LN
Mailing Address - Street 2:
Mailing Address - City:ROSLYN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11577-2509
Mailing Address - Country:US
Mailing Address - Phone:718-515-9800
Mailing Address - Fax:718-231-7942
Practice Address - Street 1:2705 WILLIAMSBRIDGE RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-4109
Practice Address - Country:US
Practice Address - Phone:718-515-9800
Practice Address - Fax:718-231-7942
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-24
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY191686174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02137768Medicaid
NYG83892Medicare UPIN
NY02137768Medicaid