Basic Information
| Provider Information | |||||||||
| NPI: | 1366737942 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANSARI | ||||||||
| FirstName: | DOMINIC | ||||||||
| MiddleName: | OMAR | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D., PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 LENORA ST # 101 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981212411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5127667512 | ||||||||
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| Practice Location | |||||||||
| Address1: | 800 E WASHINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | CRESCENT CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955318359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074648511 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2011 | ||||||||
| LastUpdateDate: | 05/29/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 285015 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.