=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134692924
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAHSA A SOHRAB MD PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2019
-----------------------------------------------------
Last Update Date | 03/18/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25 VALLEY DR STE 2B
-----------------------------------------------------
City | GREENWICH
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06831-5203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-340-1301
-----------------------------------------------------
Fax | 442-223-0286
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25 VALLEY DR
-----------------------------------------------------
City | GREENWICH
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06831-5203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-340-1301
-----------------------------------------------------
Fax | 442-223-0286
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN-OWNER
-----------------------------------------------------
Name | DR. MAHSA AVA SOHRAB
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 203-340-1301
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207WX0200X
-----------------------------------------------------
Taxonomy Name | Ophthalmic Plastic and Reconstructive Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------