Basic Information
| Provider Information | |||||||||
| NPI: | 1346777927 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANSARI | ||||||||
| FirstName: | IBN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ANSARI | ||||||||
| OtherFirstName: | MUHAMMAD | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 718 BROUGHTON ST APT 303 | ||||||||
| Address2: | |||||||||
| City: | ORANGEBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291156648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032566776 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 718 BROUGHTON ST | ||||||||
| Address2: | |||||||||
| City: | ORANGEBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291156648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6784715513 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2017 | ||||||||
| LastUpdateDate: | 08/24/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | NY | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 213ES0103X | 714 | SC | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.