Provider Demographics
NPI:1124182068
Name:ANSARI, AFTAB A (MDSC)
Entity Type:Individual
Prefix:DR
First Name:AFTAB
Middle Name:A
Last Name:ANSARI
Suffix:
Gender:M
Credentials:MDSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 30TH AVE #104
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144
Mailing Address - Country:US
Mailing Address - Phone:262-652-4878
Mailing Address - Fax:262-652-4974
Practice Address - Street 1:3601 30TH AVE #104
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144
Practice Address - Country:US
Practice Address - Phone:262-652-4878
Practice Address - Fax:262-652-4974
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO48834207X00000X
WI21598207XS0106X, 207X00000X
NDPT12136207X00000X
MI4301099576207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30186800Medicaid
B51206Medicare UPIN
32035Medicare ID - Type Unspecified
COCOA100611Medicare PIN