Provider Demographics
NPI:1689107807
Name:MANZUR, MASHAIL
Entity Type:Individual
Prefix:
First Name:MASHAIL
Middle Name:
Last Name:MANZUR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1460 MONTREAL RD E
Mailing Address - Street 2:STE 275
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1460 MONTREAL RD E
Practice Address - Street 2:STE 250
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084
Practice Address - Country:US
Practice Address - Phone:470-880-2414
Practice Address - Fax:678-802-2414
Is Sole Proprietor?:No
Enumeration Date:2017-04-05
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GAPOD001450213E00000X
FLPR507213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program