Provider Demographics
NPI:1003851726
Name:ANSARI, SHAYA (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAYA
Middle Name:
Last Name:ANSARI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8020 CONSTITUTION PL NE STE 202
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-7640
Mailing Address - Country:US
Mailing Address - Phone:505-998-3096
Mailing Address - Fax:505-998-3100
Practice Address - Street 1:8020 CONSTITUTION PL NE STE 202
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110
Practice Address - Country:US
Practice Address - Phone:505-998-3096
Practice Address - Fax:505-998-3100
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2018-06432085R0202X, 2085R0202X
FLME960272085B0100X
MO20070373102085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM79709231Medicaid
MO1003851726Medicaid
AZ406932Medicaid
MOY02000004Medicare PIN
MO37844025OtherBCBS KC GRP#18959016
MO1003851726Medicaid