Provider Demographics
NPI:1639261159
Name:ANSARI, IRADJ -
Entity Type:Individual
Prefix:DR
First Name:IRADJ
Middle Name:-
Last Name:ANSARI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16450 GULF BLVD
Mailing Address - Street 2:APT 263
Mailing Address - City:NORTH REDINGTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33708-1575
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16450 GULF BLVD
Practice Address - Street 2:APT 263
Practice Address - City:NORTH REDINGTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33708-1575
Practice Address - Country:US
Practice Address - Phone:727-398-6661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY128460282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital