Healthcare Provider Details

I. General information

NPI: 1548494529
Provider Name (Legal Business Name): MANSOOR MOZAYAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2009
Last Update Date: 07/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9105 FRANKLIN SQUARE DR STE 209
BALTIMORE MD
21237-3958
US

IV. Provider business mailing address

9105 FRANKLIN SQUARE DR STE 209
BALTIMORE MD
21237-3958
US

V. Phone/Fax

Practice location:
  • Phone: 410-574-1330
  • Fax: 410-574-2691
Mailing address:
  • Phone: 410-574-1330
  • Fax: 410-574-2691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberD0079563
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License NumberD0079563
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: