Healthcare Provider Details

I. General information

NPI: 1730366378
Provider Name (Legal Business Name): ADIL M ANSARI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2008
Last Update Date: 03/02/2023
Certification Date: 03/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 CHEROKEE ST NE STE 100
MARIETTA GA
30060-8930
US

IV. Provider business mailing address

PO BOX 339
ENON OH
45323-0339
US

V. Phone/Fax

Practice location:
  • Phone: 678-797-8201
  • Fax:
Mailing address:
  • Phone: 937-864-7363
  • Fax: 937-864-5895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35095677
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number73284
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: