Provider Demographics
NPI:1417025511
Name:MANSOURI, MARYAM BANA (OMD)
Entity Type:Individual
Prefix:DR
First Name:MARYAM
Middle Name:BANA
Last Name:MANSOURI
Suffix:
Gender:F
Credentials:OMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 LANCEWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612
Mailing Address - Country:US
Mailing Address - Phone:949-302-5921
Mailing Address - Fax:
Practice Address - Street 1:14785 JEFFREY RD
Practice Address - Street 2:STE 102
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618
Practice Address - Country:US
Practice Address - Phone:949-651-0044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC8145171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist