Provider Demographics
NPI:1174814933
Name:ANSARI, FARRUKH AZIZ (MD)
Entity Type:Individual
Prefix:DR
First Name:FARRUKH
Middle Name:AZIZ
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 1:121 EVERETT RD STE 100
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-1447
Mailing Address - Country:US
Mailing Address - Phone:518-489-2663
Mailing Address - Fax:518-689-3881
Practice Address - Street 1:121 EVERETT RD STE 100
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-1447
Practice Address - Country:US
Practice Address - Phone:518-489-2663
Practice Address - Fax:518-689-3881
Is Sole Proprietor?:No
Enumeration Date:2011-04-28
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY269588207L00000X, 208VP0000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY269588OtherNY LICENSE
NY04272804Medicaid
NY269588OtherNY LICENSE