Provider Demographics
NPI:1831244839
Name:SHIRBACHEH, MANSOUR V (MD)
Entity type:Individual
Prefix:
First Name:MANSOUR
Middle Name:V
Last Name:SHIRBACHEH
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 1:1708 YAKIMA AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-5307
Mailing Address - Country:US
Mailing Address - Phone:253-591-6739
Mailing Address - Fax:253-426-6344
Practice Address - Street 1:1708 YAKIMA AVE
Practice Address - Street 2:STE 115
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-5307
Practice Address - Country:US
Practice Address - Phone:253-682-0925
Practice Address - Fax:253-682-0927
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00041506208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1045856Medicaid