Provider Demographics
NPI:1851731145
Name:BOUSHEHRI, MANA (OD)
Entity Type:Individual
Prefix:
First Name:MANA
Middle Name:
Last Name:BOUSHEHRI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2431 N GERMANTOWN PKWY
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-4494
Mailing Address - Country:US
Mailing Address - Phone:901-214-0014
Mailing Address - Fax:901-214-0009
Practice Address - Street 1:2431 N GERMANTOWN PKWY
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016-4494
Practice Address - Country:US
Practice Address - Phone:901-214-0014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-01
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS883152W00000X
MO2013022117152W00000X
TN3135152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist