Provider Demographics
NPI:1972589950
Name:MANSOORY, AMIR (MD)
Entity Type:Individual
Prefix:
First Name:AMIR
Middle Name:
Last Name:MANSOORY
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 1:324 E MAIN ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19711-7150
Mailing Address - Country:US
Mailing Address - Phone:302-737-4990
Mailing Address - Fax:302-737-5082
Practice Address - Street 1:324 E MAIN ST
Practice Address - Street 2:SUITE 204
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19711-7150
Practice Address - Country:US
Practice Address - Phone:302-737-4990
Practice Address - Fax:302-737-5082
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-21
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1OD00529208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000027101Medicaid
D01090Medicare UPIN
DE0000027101Medicaid