Provider Demographics
NPI:1205015310
Name:MANOUTCHEHRI, AMIR HOUSHANG (MD)
Entity Type:Individual
Prefix:
First Name:AMIR
Middle Name:HOUSHANG
Last Name:MANOUTCHEHRI
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 1:12125 STATE HIGHWAY 14 N
Mailing Address - Street 2:
Mailing Address - City:CEDAR CREST
Mailing Address - State:NM
Mailing Address - Zip Code:87008-9461
Mailing Address - Country:US
Mailing Address - Phone:505-407-2174
Mailing Address - Fax:505-407-2174
Practice Address - Street 1:12125 STATE HIGHWAY 14 N
Practice Address - Street 2:
Practice Address - City:CEDAR CREST
Practice Address - State:NM
Practice Address - Zip Code:87008-9461
Practice Address - Country:US
Practice Address - Phone:505-407-2174
Practice Address - Fax:505-407-2174
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-25
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM87108207P00000X
261QP2300X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
45-2809611OtherTAX IDENTIFICATION NUMBER (TIN)
NME42476Medicare UPIN
NMNMA100561Medicare PIN