Provider Demographics
NPI:1336110238
Name:AL-ANSARI, MOHAMMED RIDA (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMED
Middle Name:RIDA
Last Name:AL-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 1:25422 GODDARD RD
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-6200
Mailing Address - Country:US
Mailing Address - Phone:313-291-5678
Mailing Address - Fax:313-291-6745
Practice Address - Street 1:25422 GODDARD RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-6200
Practice Address - Country:US
Practice Address - Phone:313-291-5678
Practice Address - Fax:313-291-6745
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI043129174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1953741Medicaid
MI1953741Medicaid
MIB44948Medicare UPIN