Provider Demographics
NPI:1780687392
Name:ANSARI, ZAEEM (MD)
Entity Type:Individual
Prefix:
First Name:ZAEEM
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 1:5079 BRIDLE PATH RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-9738
Mailing Address - Country:US
Mailing Address - Phone:315-446-5752
Mailing Address - Fax:
Practice Address - Street 1:5079 BRIDLE PATH RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-9738
Practice Address - Country:US
Practice Address - Phone:315-446-5752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY114948207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00569571Medicaid
NY00569571Medicaid
NY56133AMedicare PIN
NY56133BMedicare ID - Type UnspecifiedINDIVIDUAL