Healthcare Provider Details

I. General information

NPI: 1679702971
Provider Name (Legal Business Name): VAZRICK MANSOURIAN MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2009
Last Update Date: 07/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 SHERMAN AVE SUITE 308
NEW HAVEN CT
06511-5238
US

IV. Provider business mailing address

136 SHERMAN AVE SUITE 308
NEW HAVEN CT
06511-5238
US

V. Phone/Fax

Practice location:
  • Phone: 203-776-5819
  • Fax: 203-772-7906
Mailing address:
  • Phone: 203-776-5819
  • Fax: 203-772-7906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number015589
License Number StateCT

VIII. Authorized Official

Name: DR. VAZRICK MANSOURIAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 203-776-5819