Provider Demographics
NPI:1417958000
Name:MANSOURI, HORMOZ (MD)
Entity Type:Individual
Prefix:DR
First Name:HORMOZ
Middle Name:
Last Name:MANSOURI
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 1:175 JERICHO TPKE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-4532
Mailing Address - Country:US
Mailing Address - Phone:516-682-4800
Mailing Address - Fax:516-682-9024
Practice Address - Street 1:175 JERICHO TPKE
Practice Address - Street 2:SUITE 201
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-4532
Practice Address - Country:US
Practice Address - Phone:516-682-4800
Practice Address - Fax:516-682-9024
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY111418-12086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB20437Medicare UPIN