Provider Demographics
NPI:1518907310
Name:MASTALI, KOUROSH (MD)
Entity Type:Individual
Prefix:
First Name:KOUROSH
Middle Name:
Last Name:MASTALI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KOUROSH
Other - Middle Name:MASTALI MAJDABAD
Other - Last Name:KOHNEH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1838 GREENE TREE RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-6391
Mailing Address - Country:US
Mailing Address - Phone:410-602-9262
Mailing Address - Fax:410-602-9276
Practice Address - Street 1:7501 OSLER DR
Practice Address - Street 2:THIRD FLOOR
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-7733
Practice Address - Country:US
Practice Address - Phone:410-583-1170
Practice Address - Fax:410-583-1267
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0064509207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
G97196Medicare UPIN