Provider Demographics
NPI:1528115557
Name:DASARI, AMMANI (MD)
Entity type:Individual
Prefix:
First Name:AMMANI
Middle Name:
Last Name:DASARI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 SUMNER ST
Mailing Address - Street 2:M201
Mailing Address - City:STOUGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02072-3374
Mailing Address - Country:US
Mailing Address - Phone:781-344-2325
Mailing Address - Fax:781-341-8544
Practice Address - Street 1:909 SUMNER ST
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:MA
Practice Address - Zip Code:02072-3396
Practice Address - Country:US
Practice Address - Phone:781-344-2325
Practice Address - Fax:781-341-8544
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA38731174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAE86121Medicare UPIN
MAM09029Medicare ID - Type Unspecified