Provider Demographics
NPI:1407954134
Name:MANSOURI, GITI (MD)
Entity Type:Individual
Prefix:DR
First Name:GITI
Middle Name:
Last Name:MANSOURI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10701
Mailing Address - Country:US
Mailing Address - Phone:646-824-3314
Mailing Address - Fax:
Practice Address - Street 1:127 S BROADWAY
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701
Practice Address - Country:US
Practice Address - Phone:646-824-3314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY265547207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00246075Medicaid
NY00246075Medicaid