Provider Demographics
NPI:1053334177
Name:MANSOORI, SHAHROKH (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAHROKH
Middle Name:
Last Name:MANSOORI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 BARCLAY CIR
Mailing Address - Street 2:STE 109
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-4599
Mailing Address - Country:US
Mailing Address - Phone:248-844-2980
Mailing Address - Fax:248-844-2983
Practice Address - Street 1:135 BARCLAY CIR
Practice Address - Street 2:STE 109
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-4599
Practice Address - Country:US
Practice Address - Phone:248-844-2980
Practice Address - Fax:248-844-2983
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISM038518208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3306336001OtherBLUE CROSS
MI1404338Medicaid
MI3306336001OtherBLUE CROSS
MI1404338Medicaid