Provider Demographics
NPI:1417324633
Name:ANSARI, SHAHNAWAZ (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAHNAWAZ
Middle Name:
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 1:7102 STOCKYARD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-0188
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2101 N WATERMAN AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-4836
Practice Address - Country:US
Practice Address - Phone:909-883-8711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-24
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJPERMIT2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology