Healthcare Provider Details

I. General information

NPI: 1639758089
Provider Name (Legal Business Name): WASILA MANSOURI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2021
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 MAIN ST
WALPOLE MA
02081-1718
US

IV. Provider business mailing address

11 COOPER AVE
TROY NY
12180-2703
US

V. Phone/Fax

Practice location:
  • Phone: 508-668-2200
  • Fax:
Mailing address:
  • Phone: 518-961-0666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1019919
License Number StateMA

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: