Provider Demographics
NPI:1013913102
Name:BANSAL, ANKUSH KUMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:ANKUSH
Middle Name:KUMAR
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 1:14611 SOUTHERN BLVD
Mailing Address - Street 2:1082
Mailing Address - City:LOXAHATCHEE
Mailing Address - State:FL
Mailing Address - Zip Code:33470-6801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14611 SOUTHERN BLVD
Practice Address - Street 2:1082
Practice Address - City:LOXAHATCHEE
Practice Address - State:FL
Practice Address - Zip Code:33470-6801
Practice Address - Country:US
Practice Address - Phone:703-646-1869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1244797207R00000X
CAA110949207R00000X
MO2011035989207R00000X
WI50291-020207R00000X
VA0101246131207R00000X
ME18320207R00000X, 208M00000X
NJ25MA08633100207R00000X
NY254229207R00000X
WV25465207R00000X
CODR.0055143208M00000X
FLME105948207R00000X
PAMD432005207R00000X
IL036134319207R00000X
TN51061207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
64836 C005OtherTRICARE
MA2082235OtherMEDICARE 855I
MA3446096OtherMEDICARE 855R
64836 C005OtherTRICARE