Provider Demographics
NPI:1962646687
Name:ANSAL, ASHISH MANI (MD)
Entity Type:Individual
Prefix:DR
First Name:ASHISH
Middle Name:MANI
Last Name:ANSAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ASHISH
Other - Middle Name:
Other - Last Name:ANSAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2045 W. WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-2428
Mailing Address - Country:US
Mailing Address - Phone:312-996-2000
Mailing Address - Fax:312-413-7812
Practice Address - Street 1:2045 W. WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-2428
Practice Address - Country:US
Practice Address - Phone:312-996-2000
Practice Address - Fax:312-413-7812
Is Sole Proprietor?:No
Enumeration Date:2009-04-24
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL390200000X
IL036.130215207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036.130215Medicaid