MEDICARE: SHAJIA RAHMAN ANSARI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	694201	TX

General Provider Information

NPI Number	:	1093277956
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAJIA RAHMAN ANSARI

Provider Business Mailing Address
First Line	:	5767 W CENTURY BLVD STE 400
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-5631
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10833 LE CONTE AVE STE AS-370
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90095-4056
Country	:	US
Telephone Number	:	310-267-2680
Fax Number	:	310-267-2685

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/01/2019
Last Update Date	:	07/13/2023

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