Provider Demographics
NPI:1639758089
Name:MANSOURI, WASILA (MD)
Entity type:Individual
Prefix:
First Name:WASILA
Middle Name:
Last Name:MANSOURI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 COOPER AVE
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-2703
Mailing Address - Country:US
Mailing Address - Phone:518-961-0666
Mailing Address - Fax:
Practice Address - Street 1:1350 MAIN ST
Practice Address - Street 2:
Practice Address - City:WALPOLE
Practice Address - State:MA
Practice Address - Zip Code:02081-1718
Practice Address - Country:US
Practice Address - Phone:508-668-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-05
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1019919208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics