Provider Demographics
NPI:1477744068
Name:MANSOURI, AZAD (MD)
Entity Type:Individual
Prefix:DR
First Name:AZAD
Middle Name:
Last Name:MANSOURI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3495 PIEDMONT RD NE
Mailing Address - Street 2:NINE PIEDMONT CENTER
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-1717
Mailing Address - Country:US
Mailing Address - Phone:404-504-5678
Mailing Address - Fax:410-339-7326
Practice Address - Street 1:2400 MOUNT ZION PKWY
Practice Address - Street 2:KAISER PERMANENTE SOUTHWOOD MEDICAL CENTER
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-2500
Practice Address - Country:US
Practice Address - Phone:410-337-4500
Practice Address - Fax:410-339-7326
Is Sole Proprietor?:No
Enumeration Date:2007-08-07
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101247198207W00000X
MDD70402207W00000X
MO2006017512207W00000X
GA076153207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1477744068Medicaid
MD033505300Medicaid
DC078242200Medicaid
VA1477744068Medicaid
VAVAA100405Medicare PIN