Provider Demographics
NPI:1457866519
Name:ANSARI, MOHAMMAD JAMAL UDDIN (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:JAMAL UDDIN
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 1:292 SAINT CHARLES WAY
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-4648
Mailing Address - Country:US
Mailing Address - Phone:717-851-6231
Mailing Address - Fax:717-741-1719
Practice Address - Street 1:292 SAINT CHARLES WAY
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17402-4648
Practice Address - Country:US
Practice Address - Phone:717-851-6231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036145361207RE0101X
PAMD469208207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103793784Medicaid
PA103793784Medicaid