Provider Demographics
NPI:1841458783
Name:BANSAL, GOLDY (MD)
Entity type:Individual
Prefix:DR
First Name:GOLDY
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 996
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-0996
Mailing Address - Country:US
Mailing Address - Phone:208-664-4026
Mailing Address - Fax:208-664-4840
Practice Address - Street 1:3911 CASTLEVALE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-7807
Practice Address - Country:US
Practice Address - Phone:509-454-9499
Practice Address - Fax:509-457-4994
Is Sole Proprietor?:No
Enumeration Date:2008-05-28
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAMD60217451207RH0000X, 207RX0202X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6298960001Medicare NSC