MEDICARE: DR. HORMOZ MANSOURI M.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2086S0129X	Vascular Surgery Physician	111418-1	NY

General Provider Information

NPI Number	:	1417958000
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HORMOZ MANSOURI M.D

Provider Business Mailing Address
First Line	:	175 JERICHO TPKE
Second Line	:	SUITE 201
City	:	SYOSSET
State	:	NY
Zip	:	11791-4532
Country	:	US
Telephone Number	:	516-682-4800
Fax Number	:	516-682-9024

Provider Business Practice Location Address
First Line	:	175 JERICHO TPKE
Second Line	:	SUITE 201
City	:	SYOSSET
State	:	NY
Zip	:	11791-4532
Country	:	US
Telephone Number	:	516-682-4800
Fax Number	:	516-682-9024

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2005
Last Update Date	:	07/08/2007

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