Healthcare Provider Details

I. General information

NPI: 1992768477
Provider Name (Legal Business Name): RAMIL MANSOUROV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 06/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 MAIN ST
NORWALK CT
06851-2720
US

IV. Provider business mailing address

235 MAIN ST
NORWALK CT
06851-2720
US

V. Phone/Fax

Practice location:
  • Phone: 203-644-4775
  • Fax: 203-547-6118
Mailing address:
  • Phone: 203-644-4775
  • Fax: 203-547-6118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code193200000X
TaxonomyMulti-Specialty Group
License Number040028
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number44050
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9376
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: