Provider Demographics
NPI:1992891220
Name:BANSIDHAR, BRIAN JOSEPH (DO)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:JOSEPH
Last Name:BANSIDHAR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4125 W RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-1763
Mailing Address - Country:US
Mailing Address - Phone:814-833-1119
Mailing Address - Fax:814-833-1138
Practice Address - Street 1:4125 W RIDGE RD
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-1763
Practice Address - Country:US
Practice Address - Phone:814-833-1119
Practice Address - Fax:814-833-1138
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS-010801L208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHI32687Medicare UPIN