Provider Demographics
NPI:1073629424
Name:NASIM, MANSOOR M (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:MANSOOR
Middle Name:M
Last Name:NASIM
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270-05 76TH AVE, B68
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-1402
Mailing Address - Country:US
Mailing Address - Phone:718-470-7490
Mailing Address - Fax:718-347-9171
Practice Address - Street 1:270-05 76TH AVE, B68
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-1402
Practice Address - Country:US
Practice Address - Phone:718-470-7490
Practice Address - Fax:718-347-9171
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY236585207ZP0101X
DCMD035352207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD408656200Medicaid
VA010197171Medicaid
DC037027800Medicaid
MD408656200Medicaid
017945H13Medicare PIN