Provider Demographics
NPI:1700938297
Name:ANSARI, ALTAF (MD)
Entity Type:Individual
Prefix:
First Name:ALTAF
Middle Name:
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 1:407 AIRPORT EXE PARK
Mailing Address - Street 2:
Mailing Address - City:NANUET
Mailing Address - State:NY
Mailing Address - Zip Code:10954
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2500 MILVIA ST
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-2636
Practice Address - Country:US
Practice Address - Phone:510-204-5514
Practice Address - Fax:510-204-5515
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY164300207P00000X, 207R00000X
CA352047207R00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01016366Medicaid
CAC56132OtherSTATE MEDICAL LICENSE
NY01016366Medicaid