Provider Demographics
NPI:1922053008
Name:BANSAL, SUDHA (MD)
Entity Type:Individual
Prefix:DR
First Name:SUDHA
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:PO BOX 1476
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-7476
Mailing Address - Country:US
Mailing Address - Phone:517-264-5820
Mailing Address - Fax:
Practice Address - Street 1:415 MILL RD
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1764
Practice Address - Country:US
Practice Address - Phone:517-264-5820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301404631207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4500632Medicaid
MIF93604Medicare UPIN
MIOM22830Medicare ID - Type Unspecified