Provider Demographics
NPI:1689661019
Name:MANSOURI, MEHRAN
Entity type:Individual
Prefix:
First Name:MEHRAN
Middle Name:
Last Name:MANSOURI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 CENTRAL PARK ROAD
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-5018
Mailing Address - Country:US
Mailing Address - Phone:516-719-3060
Mailing Address - Fax:516-719-3061
Practice Address - Street 1:25 CENTRAL PARK RD
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-2001
Practice Address - Country:US
Practice Address - Phone:516-719-3060
Practice Address - Fax:516-719-3061
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY16089812086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
B10436Medicare UPIN
0256H1Medicare ID - Type Unspecified