Provider Demographics
NPI:1073932612
Name:VASCONCELLOS, MANSI SHAH (MD)
Entity Type:Individual
Prefix:
First Name:MANSI
Middle Name:SHAH
Last Name:VASCONCELLOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MANSI
Other - Middle Name:GAUTAM
Other - Last Name:SHAH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1600 ROCKLAND RD
Mailing Address - Street 2:SUITE 2B80
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19803-3607
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1600 ROCKLAND RD
Practice Address - Street 2:SUITE 2B80
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-3607
Practice Address - Country:US
Practice Address - Phone:302-651-5874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-10
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAMD461950208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program