Provider Demographics
NPI:1972831782
Name:TASADDAQ, AYESHA (MD)
Entity Type:Individual
Prefix:
First Name:AYESHA
Middle Name:
Last Name:TASADDAQ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AYESHA
Other - Middle Name:
Other - Last Name:RIASAT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 601
Mailing Address - Street 2:10869 RTE 36 SOUTH
Mailing Address - City:DANSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14437-0601
Mailing Address - Country:US
Mailing Address - Phone:585-335-3416
Mailing Address - Fax:585-335-8695
Practice Address - Street 1:60 RED JACKET ST
Practice Address - Street 2:SUITE 1
Practice Address - City:DANSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14437-0339
Practice Address - Country:US
Practice Address - Phone:585-335-6041
Practice Address - Fax:585-335-6764
Is Sole Proprietor?:No
Enumeration Date:2009-12-07
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY258140207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03252595Medicaid
NYJ400027930Medicare PIN