Healthcare Provider Details

I. General information

NPI: 1720110182
Provider Name (Legal Business Name): MANOOCHEHR MAZLOOMDOOST P S C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 08/17/2022
Certification Date: 08/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 CUMBERLAND FALLS HWY
CORBIN KY
40701-2715
US

IV. Provider business mailing address

101 N EAGLE CREEK DR
LEXINGTON KY
40509-1806
US

V. Phone/Fax

Practice location:
  • Phone: 859-275-4878
  • Fax:
Mailing address:
  • Phone: 859-275-4878
  • Fax: 859-276-5400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number17083
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code2084P2900X
TaxonomyPain Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. DANESH MAZLOOMDOOST
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 859-275-4878