Provider Demographics
NPI:1700801610
Name:MANTOURA, AMIRA (DPM)
Entity Type:Individual
Prefix:DR
First Name:AMIRA
Middle Name:
Last Name:MANTOURA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:DR
Other - First Name:AMIRA
Other - Middle Name:
Other - Last Name:NANAI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPM
Mailing Address - Street 1:95 MORGAN ST
Mailing Address - Street 2:SUITE 1J
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-5474
Mailing Address - Country:US
Mailing Address - Phone:203-975-1175
Mailing Address - Fax:203-978-0641
Practice Address - Street 1:95 MORGAN ST
Practice Address - Street 2:SUITE 1J
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-5474
Practice Address - Country:US
Practice Address - Phone:203-975-1175
Practice Address - Fax:203-978-0641
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000430213E00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4078029Medicaid
CT480000343Medicare ID - Type Unspecified
CTT22256Medicare UPIN