Provider Demographics
NPI:1184937245
Name:ANSARI, MUHAMMAD SHAHZAD MUMTAZ (MD)
Entity type:Individual
Prefix:DR
First Name:MUHAMMAD SHAHZAD
Middle Name:MUMTAZ
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 1:707 E CEDAR ST
Mailing Address - Street 2:STE 200
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2057
Mailing Address - Country:US
Mailing Address - Phone:574-335-8700
Mailing Address - Fax:
Practice Address - Street 1:5215 HOLY CROSS PKWY
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1469
Practice Address - Country:US
Practice Address - Phone:574-335-4145
Practice Address - Fax:574-335-4146
Is Sole Proprietor?:No
Enumeration Date:2010-07-19
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036132394208000000X
WI82081-202080N0001X
IN01076678A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000001019988OtherANTHEM BCBS