Provider Demographics
NPI:1114045812
Name:ANSARI, ASMA RAFEEQ (MD)
Entity Type:Individual
Prefix:DR
First Name:ASMA
Middle Name:RAFEEQ
Last Name:ANSARI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ASMA
Other - Middle Name:
Other - Last Name:RAFEEQ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:159 S BLOOMINGDALE RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-1434
Mailing Address - Country:US
Mailing Address - Phone:630-529-5950
Mailing Address - Fax:630-529-6286
Practice Address - Street 1:159 S BLOOMINGDALE RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-1434
Practice Address - Country:US
Practice Address - Phone:630-529-5950
Practice Address - Fax:630-529-6286
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036122782207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL336084349OtherCONTROLLED SUBSTANCE LICENSE
OH35.122131OtherMEDICAL LICENSE
IL036122782OtherMEDICAL LICENSE NUMBER
ILP00906492OtherRAILROAD MEDICARE