Provider Demographics
NPI:1538241245
Name:VIR, BANI (MD)
Entity type:Individual
Prefix:
First Name:BANI
Middle Name:
Last Name:VIR
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 1:1333 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10018-7204
Mailing Address - Country:US
Mailing Address - Phone:212-849-0146
Mailing Address - Fax:
Practice Address - Street 1:1333 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-7204
Practice Address - Country:US
Practice Address - Phone:212-849-0146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08099900207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8751404Medicaid
NJ063701Medicare ID - Type UnspecifiedMEDICARE FACILITY