Healthcare Provider Details

I. General information

NPI: 1629000112
Provider Name (Legal Business Name): MAHNAZ NOURI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 11/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 COMMONWEALTH AVE STE 2
BOSTON MA
02215-2813
US

IV. Provider business mailing address

250 HAMMOND POND PKWY UNIT 505NORTH
CHESTNUT HILL MA
02467-1533
US

V. Phone/Fax

Practice location:
  • Phone: 617-651-0938
  • Fax:
Mailing address:
  • Phone: 617-651-0938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number209639
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: