Healthcare Provider Details

I. General information

NPI: 1003851726
Provider Name (Legal Business Name): SHAYA ANSARI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 07/10/2025
Certification Date: 07/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 DAKOTA DR
NEW HYDE PARK NY
11042-1135
US

IV. Provider business mailing address

8020 CONSTITUTION PL NE STE 202
ALBUQUERQUE NM
87110-7640
US

V. Phone/Fax

Practice location:
  • Phone: 516-622-6100
  • Fax: 516-608-6812
Mailing address:
  • Phone: 505-998-3096
  • Fax: 505-998-3100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101281884
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4301512042
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD2018-0643
License Number StateNM
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number222637
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: