Provider Demographics
NPI:1194179887
Name:MANSURI, SOOHAN (MD)
Entity Type:Individual
Prefix:
First Name:SOOHAN
Middle Name:
Last Name:MANSURI
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:PO BOX 1935
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-0935
Mailing Address - Country:US
Mailing Address - Phone:570-288-8881
Mailing Address - Fax:
Practice Address - Street 1:511 PIERCE ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-5731
Practice Address - Country:US
Practice Address - Phone:570-714-3333
Practice Address - Fax:570-338-3993
Is Sole Proprietor?:No
Enumeration Date:2016-04-19
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD467882207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1032455380003Medicaid