Provider Demographics
NPI:1376532747
Name:MANSOURI, MEHRDAD ALI (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:MEHRDAD
Middle Name:ALI
Last Name:MANSOURI
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 1:528 CLYNE CT
Mailing Address - Street 2:
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510-3842
Mailing Address - Country:US
Mailing Address - Phone:707-365-7039
Mailing Address - Fax:
Practice Address - Street 1:2500 ALHAMBRA AVE
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553-3156
Practice Address - Country:US
Practice Address - Phone:925-370-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-18
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA101584208M00000X
GA056602208D00000X
IL125057985207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice