Healthcare Provider Details

I. General information

NPI: 1194789370
Provider Name (Legal Business Name): MANSUR E. SHOMALI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 12/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E 33RD ST 33RD ST PROF BLDG, STE 551
BALTIMORE MD
21218-3322
US

IV. Provider business mailing address

200 E 33RD ST 33RD ST PROF BLDG, STE 551
BALTIMORE MD
21218-3322
US

V. Phone/Fax

Practice location:
  • Phone: 410-554-4511
  • Fax: 410-554-6490
Mailing address:
  • Phone: 410-554-4511
  • Fax: 410-554-6490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberD0058521
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: