Healthcare Provider Details

I. General information

NPI: 1841236312
Provider Name (Legal Business Name): EHSAN ANSARI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: EHSAN ANSARI M.D.

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 03/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 CHASE PKWY
WATERBURY CT
06708-3352
US

IV. Provider business mailing address

455 CHASE PKWY
WATERBURY CT
06708-3303
US

V. Phone/Fax

Practice location:
  • Phone: 203-573-1435
  • Fax: 203-755-7433
Mailing address:
  • Phone: 203-573-1435
  • Fax: 203-755-7433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number043316
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number043316
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number043316
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: