Healthcare Provider Details

I. General information

NPI: 1477612877
Provider Name (Legal Business Name): ATHAR MASOOD ANSARI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 W ORANGE AVE STE. B
EL CENTRO CA
92243-3274
US

IV. Provider business mailing address

PO BOX 2575
ALPINE CA
91903-2575
US

V. Phone/Fax

Practice location:
  • Phone: 760-353-3222
  • Fax:
Mailing address:
  • Phone: 760-484-3937
  • Fax: 760-353-3311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberA50706
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: