Provider Demographics
NPI:1710121132
Name:MASTOURI, NASIM
Entity Type:Individual
Prefix:
First Name:NASIM
Middle Name:
Last Name:MASTOURI
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 1:1001 BELLEFONTAINE AVE
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-2800
Mailing Address - Country:US
Mailing Address - Phone:419-998-4575
Mailing Address - Fax:419-998-4586
Practice Address - Street 1:1005 BELLEFONTAINE AVE
Practice Address - Street 2:SUITE 230
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-2851
Practice Address - Country:US
Practice Address - Phone:419-998-8255
Practice Address - Fax:419-226-8335
Is Sole Proprietor?:No
Enumeration Date:2009-04-29
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.120131207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0072864Medicaid
WV3810024141Medicaid
OHH139710Medicare PIN