Provider Demographics
NPI:1164520581
Name:ANSARI, MOHAMMAD ALI (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:ALI
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:PO BOX 935
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90213-0935
Mailing Address - Country:US
Mailing Address - Phone:310-433-2750
Mailing Address - Fax:
Practice Address - Street 1:6310 SAN VICENTE BLVD
Practice Address - Street 2:SUITE 280
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5426
Practice Address - Country:US
Practice Address - Phone:323-934-9265
Practice Address - Fax:323-934-9266
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG75046207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G750460Medicaid
CA20-2917859OtherFEDERAL TAX I.D. NUMBER
CAG75046OtherLICENSE NUMBER
CAF81916Medicare UPIN
CAG75046OtherLICENSE NUMBER