Healthcare Provider Details

I. General information

NPI: 1093978165
Provider Name (Legal Business Name): ANSERUDDIN MOHAMMED M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2008
Last Update Date: 05/13/2025
Certification Date: 05/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 WALNUT ST WALNUT PLAZA
JOHNSTOWN PA
15901-1625
US

IV. Provider business mailing address

1086 FRANKLIN ST
JOHNSTOWN PA
15905-4305
US

V. Phone/Fax

Practice location:
  • Phone: 814-534-1095
  • Fax: 814-534-6145
Mailing address:
  • Phone: 814-410-8300
  • Fax: 814-410-8331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberU5298
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4301093935
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036165779
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD441808
License Number StatePA
# 5
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number4301093935
License Number StateMI
# 6
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number0101283480
License Number StateVA
# 7
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number036165779
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: