Provider Demographics
NPI:1053604389
Name:MANSOURI, BOBBAK (MD)
Entity type:Individual
Prefix:DR
First Name:BOBBAK
Middle Name:
Last Name:MANSOURI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1367 DOMINION PLZ
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-1013
Mailing Address - Country:US
Mailing Address - Phone:903-534-6200
Mailing Address - Fax:
Practice Address - Street 1:508 MEDICAL CENTER BLVD STE 380
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-2954
Practice Address - Country:US
Practice Address - Phone:281-573-8333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-19
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP6025207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology