Provider Demographics
NPI:1295704047
Name:EHTESHAMI, MANI (MD)
Entity type:Individual
Prefix:
First Name:MANI
Middle Name:
Last Name:EHTESHAMI
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 1:27 CLERMONT
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92657-1069
Mailing Address - Country:US
Mailing Address - Phone:949-706-2796
Mailing Address - Fax:949-706-2072
Practice Address - Street 1:27 CLERMONT
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92657-1069
Practice Address - Country:US
Practice Address - Phone:949-706-2796
Practice Address - Fax:949-706-2072
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG74263207ZC0500X, 207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G12183Medicare UPIN