Provider Demographics
NPI:1184056996
Name:ANSARI-DEZFULI, MOHAMMAD
Entity type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:
Last Name:ANSARI-DEZFULI
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:MOHAMMAD
Other - Middle Name:
Other - Last Name:ANSARI-DEZFULI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1700 CARRIAGE PLACE
Mailing Address - Street 2:
Mailing Address - City:GATES MILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44040
Mailing Address - Country:US
Mailing Address - Phone:440-449-7577
Mailing Address - Fax:
Practice Address - Street 1:1700 CARRIAGE PLACE
Practice Address - Street 2:
Practice Address - City:GATES MILLS
Practice Address - State:OH
Practice Address - Zip Code:44040
Practice Address - Country:US
Practice Address - Phone:440-449-7577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-02
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35. 040149207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology