Healthcare Provider Details

I. General information

NPI: 1821294455
Provider Name (Legal Business Name): SHAUKAT ALI ANSARI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2007
Last Update Date: 02/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 N CALIFORNIA ST
STOCKTON CA
95202-1515
US

IV. Provider business mailing address

1414 N CALIFORNIA ST
STOCKTON CA
95202-1515
US

V. Phone/Fax

Practice location:
  • Phone: 209-468-2391
  • Fax: 209-468-8024
Mailing address:
  • Phone: 209-468-2391
  • Fax: 209-468-8024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number35.089369
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA105923
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: