Provider Demographics
NPI:1144218629
Name:SALARI, MANSOOREH (MD)
Entity type:Individual
Prefix:
First Name:MANSOOREH
Middle Name:
Last Name:SALARI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MANSOOREH
Other - Middle Name:
Other - Last Name:RAISSIAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1290 GOLFVIEW AVE
Mailing Address - Street 2:4TH FLOOR BILLING DEPARTMENT
Mailing Address - City:BARTOW
Mailing Address - State:FL
Mailing Address - Zip Code:33830-6738
Mailing Address - Country:US
Mailing Address - Phone:863-519-7900
Mailing Address - Fax:863-519-7696
Practice Address - Street 1:3241 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-2266
Practice Address - Country:US
Practice Address - Phone:863-413-2620
Practice Address - Fax:863-499-2612
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME33945208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL038707000Medicaid
11206ZMedicare ID - Type Unspecified
E66276Medicare UPIN