Provider Demographics
NPI:1124463179
Name:AHSAN, IRFAN (DPM)
Entity type:Individual
Prefix:MR
First Name:IRFAN
Middle Name:
Last Name:AHSAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8510 BALBOA BLVD STE 150
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-5810
Mailing Address - Country:US
Mailing Address - Phone:818-654-3400
Mailing Address - Fax:818-654-3417
Practice Address - Street 1:191 S BUENA VISTA ST STE 235
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4563
Practice Address - Country:US
Practice Address - Phone:818-980-9393
Practice Address - Fax:818-654-3417
Is Sole Proprietor?:No
Enumeration Date:2013-05-03
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LADPM200072213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00654772Medicaid
LA2333984Medicaid
LA2333984Medicaid
LA531949YH3UMedicare PIN