Provider Demographics
NPI:1881663615
Name:BANSAL, ARCHANA (MD)
Entity Type:Individual
Prefix:
First Name:ARCHANA
Middle Name:
Last Name:BANSAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 N CORONADO DR
Mailing Address - Street 2:#C
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-6360
Mailing Address - Country:US
Mailing Address - Phone:520-458-4335
Mailing Address - Fax:520-458-2988
Practice Address - Street 1:157 N CORONADO DR
Practice Address - Street 2:#C
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-6360
Practice Address - Country:US
Practice Address - Phone:520-458-4335
Practice Address - Fax:520-458-2988
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18964207Q00000X
AZ35263207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ098186Medicaid
AZZ110022Medicare PIN
AZ098186Medicaid