Provider Demographics
NPI:1346777927
Name:ANSARI, IBN (DPM)
Entity Type:Individual
Prefix:DR
First Name:IBN
Middle Name:
Last Name:ANSARI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:MUHAMMAD
Other - Middle Name:
Other - Last Name:ANSARI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:718 BROUGHTON ST APT 303
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-6648
Mailing Address - Country:US
Mailing Address - Phone:803-256-6776
Mailing Address - Fax:
Practice Address - Street 1:718 BROUGHTON ST
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-6648
Practice Address - Country:US
Practice Address - Phone:803-531-2888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-15
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC714213ES0103X
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program