Provider Demographics
NPI:1992938765
Name:BANSAL, MUKTA (MD)
Entity type:Individual
Prefix:
First Name:MUKTA
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 1:113 ROUTE 73
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-9573
Mailing Address - Country:US
Mailing Address - Phone:856-809-3500
Mailing Address - Fax:
Practice Address - Street 1:113 ROUTE 73
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-9573
Practice Address - Country:US
Practice Address - Phone:856-809-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-27
Last Update Date:2014-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09307500207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine