Provider Demographics
NPI:1386617603
Name:BANSAL, RAJ KUMAR (MD)
Entity type:Individual
Prefix:
First Name:RAJ
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 1:870 CRESTMARK DR
Mailing Address - Street 2:STE 201
Mailing Address - City:LITHIA SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30122
Mailing Address - Country:US
Mailing Address - Phone:770-739-5242
Mailing Address - Fax:770-739-5204
Practice Address - Street 1:870 CRESTMARK DR
Practice Address - Street 2:STE 201
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122
Practice Address - Country:US
Practice Address - Phone:770-739-5242
Practice Address - Fax:770-739-5204
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048412207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00864421EMedicaid
F82413Medicare UPIN
GA16BBBTTMedicare ID - Type Unspecified