Basic Information
| Provider Information | |||||||||
| NPI: | 1578659322 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANSAL | ||||||||
| FirstName: | JATINDER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 345 COLLEGE ST SE | ||||||||
| Address2: | STE C | ||||||||
| City: | LACEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985031014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3609234330 | ||||||||
| FaxNumber: | 3604563894 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 STATION DR | ||||||||
| Address2: | #150 | ||||||||
| City: | DUPONT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983279804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539122020 | ||||||||
| FaxNumber: | 2535791153 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 09/13/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OD4053 | WA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 2012279 | 05 | WA | MEDICAID |