Provider Demographics
NPI:1689830572
Name:MANSOURI, FARSHAD (MD)
Entity Type:Individual
Prefix:
First Name:FARSHAD
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 1:741 TEANECK RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-4243
Mailing Address - Country:US
Mailing Address - Phone:716-523-7930
Mailing Address - Fax:
Practice Address - Street 1:741 TEANECK RD
Practice Address - Street 2:SUITE B
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-4243
Practice Address - Country:US
Practice Address - Phone:716-523-7930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-31
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08363900208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MA08363900OtherLICENSE