Basic Information
| Provider Information | |||||||||
| NPI: | 1245219997 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANSARI | ||||||||
| FirstName: | IBAD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 E 75TH ST | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502805 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1402 E COUNTY LINE RD | ||||||||
| Address2: | SUITE 2400 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462270963 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178877880 | ||||||||
| FaxNumber: | 3178877660 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2006 | ||||||||
| LastUpdateDate: | 06/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 01035152A | IN | N | Other Service Providers | Specialist | 207RC0000X | 01035152A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 200539450A | 05 | IN | MEDICAID | P01214593 | 01 | IN | RR MEDICARE PTAN | OTHER | P01215493 | 01 | IN | RR MEDICARE PTAN | OTHER |