Provider Demographics
NPI:1932102456
Name:BANSAL, JAGAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JAGAN
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 1:5540 N FIGUEROA ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-4120
Mailing Address - Country:US
Mailing Address - Phone:323-478-1101
Mailing Address - Fax:
Practice Address - Street 1:5540 N FIGUEROA ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90042-4120
Practice Address - Country:US
Practice Address - Phone:323-478-1101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-30
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34128207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA84573Medicare UPIN
WA34128LMedicare UPIN