Provider Demographics
NPI:1184449332
Name:MRIDHA, BANSHARI
Entity type:Individual
Prefix:
First Name:BANSHARI
Middle Name:
Last Name:MRIDHA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 WILLOW WOOD LN FL 2
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10308-1868
Mailing Address - Country:US
Mailing Address - Phone:347-530-4010
Mailing Address - Fax:
Practice Address - Street 1:15 SAINT PAULS PL
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-2636
Practice Address - Country:US
Practice Address - Phone:516-466-3001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-21
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP130582207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine