Healthcare Provider Details

I. General information

NPI: 1689661019
Provider Name (Legal Business Name): MEHRAN MANSOURI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 07/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 CENTRAL PARK RD
PLAINVIEW NY
11803-2001
US

IV. Provider business mailing address

25 CENTRAL PARK ROAD
PLAINVIEW NY
11803-5018
US

V. Phone/Fax

Practice location:
  • Phone: 516-719-3060
  • Fax: 516-719-3061
Mailing address:
  • Phone: 516-719-3060
  • Fax: 516-719-3061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number1608981
License Number StateNY

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: