Provider Demographics
NPI:1477612877
Name:ANSARI, ATHAR MASOOD (MD)
Entity Type:Individual
Prefix:DR
First Name:ATHAR
Middle Name:MASOOD
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 2575
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:CA
Mailing Address - Zip Code:91903-2575
Mailing Address - Country:US
Mailing Address - Phone:760-484-3937
Mailing Address - Fax:760-353-3311
Practice Address - Street 1:790 W ORANGE AVE
Practice Address - Street 2:STE. B
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-3274
Practice Address - Country:US
Practice Address - Phone:760-353-3222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50706207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA50706Medicare ID - Type UnspecifiedMEDICARE PROVIDER NO.
CAG25776Medicare UPIN