Provider Demographics
NPI:1114126034
Name:FRED AND MARY MANSUBI, M.D. A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:FRED AND MARY MANSUBI, M.D. A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MEHRI (MARY)
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSUBI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-358-2627
Mailing Address - Street 1:2577 SAMARITAN DR
Mailing Address - Street 2:SUITE 860
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124-4100
Mailing Address - Country:US
Mailing Address - Phone:408-358-2627
Mailing Address - Fax:408-356-6445
Practice Address - Street 1:2577 SAMARITAN DR
Practice Address - Street 2:SUITE 860
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-4100
Practice Address - Country:US
Practice Address - Phone:408-358-2627
Practice Address - Fax:408-356-6445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-11
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA330510208000000X
CAA2628902080P0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/ImmunologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA24794Medicare UPIN
CAA33051Medicare UPIN