Provider Demographics
NPI:1780045310
Name:ANSARI, AMBREEN S (DO)
Entity Type:Individual
Prefix:
First Name:AMBREEN
Middle Name:S
Last Name:ANSARI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 E SPRING ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-2469
Mailing Address - Country:US
Mailing Address - Phone:770-464-0280
Mailing Address - Fax:770-464-0233
Practice Address - Street 1:855 W BROAD ST STE A
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30601-2511
Practice Address - Country:US
Practice Address - Phone:706-850-6134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-09
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA86484207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program