Healthcare Provider Details

I. General information

NPI: 1386184620
Provider Name (Legal Business Name): SAPOORA MANSHAII MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2017
Last Update Date: 03/09/2024
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N MCDOWELL BLVD
PETALUMA CA
94954-2339
US

IV. Provider business mailing address

2500 EXETER SQUARE LN
SACRAMENTO CA
95825-6476
US

V. Phone/Fax

Practice location:
  • Phone: 707-778-1111
  • Fax:
Mailing address:
  • Phone: 916-862-1819
  • Fax: 916-224-3840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberC54919
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberC54919
License Number StateCA

VIII. Authorized Official

Name: DR. SAPOORA MANSHAII
Title or Position: OWNER / PROVIDER
Credential: M.D.
Phone: 916-862-1819