Provider Demographics
NPI:1013955061
Name:MANDANIPOUR, BEHROOZ (DPM)
Entity Type:Individual
Prefix:DR
First Name:BEHROOZ
Middle Name:
Last Name:MANDANIPOUR
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1332 E 36TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-2704
Mailing Address - Country:US
Mailing Address - Phone:718-926-8855
Mailing Address - Fax:646-308-9202
Practice Address - Street 1:1332 E 36TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-2704
Practice Address - Country:US
Practice Address - Phone:718-926-8855
Practice Address - Fax:646-308-9202
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005601213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02369946Medicaid
A300041434OtherPTAN#
NY02369946Medicaid
A300041434OtherPTAN#