Provider Demographics
NPI:1487602686
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 1:500 GROVE ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HADDON HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:08035-1761
Mailing Address - Country:US
Mailing Address - Phone:856-796-9200
Mailing Address - Fax:856-796-9397
Practice Address - Street 1:218A SUNSET RD
Practice Address - Street 2:LOURDES MEDICAL CENTER BURLINGTON COUNTY
Practice Address - City:WILLINGBORO
Practice Address - State:NJ
Practice Address - Zip Code:08046-1110
Practice Address - Country:US
Practice Address - Phone:609-835-3056
Practice Address - Fax:609-835-3061
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06499700207R00000X, 208M00000X
PAMD059329L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00795381OtherRR MEDICARE - LOWER BUCKS
PA30059865OtherKEYSTONE MERCY-LOWER BUCKS GROUP
PAP00765936OtherRR MEDICARE
NJ0106861Medicaid
PA1014215290004Medicaid
PA30061308OtherKEYSTONE MERCY
PA095968ZCHMMedicare PIN
PA1014215290004Medicaid
PA095968ZDKTMedicare PIN