Provider Demographics
NPI:1629029871
Name:MARJANI, MASOUD A (MD)
Entity Type:Individual
Prefix:DR
First Name:MASOUD
Middle Name:A
Last Name:MARJANI
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 1:134 GRANDVIEW AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2507
Mailing Address - Country:US
Mailing Address - Phone:203-756-9288
Mailing Address - Fax:203-573-7270
Practice Address - Street 1:134 GRANDVIEW AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2507
Practice Address - Country:US
Practice Address - Phone:203-756-9288
Practice Address - Fax:203-573-7270
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT014770174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT014770OtherCONNECTICARE
CT010014770CT02OtherANTHEM
OR094SOtherHEALTHNET
NHS012OtherOXFORD
CT014770OtherCONNECTICARE