Provider Demographics
NPI:1356436612
Name:MANSOURIAN, AMIR (MD)
Entity type:Individual
Prefix:
First Name:AMIR
Middle Name:
Last Name:MANSOURIAN
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:PO BOX 31592
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-8592
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1278 N MONTECITO DR
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94521-5510
Practice Address - Country:US
Practice Address - Phone:925-753-1986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2015-07-16
Deactivation Date:2013-09-10
Deactivation Code:
Reactivation Date:2015-07-16
Provider Licenses
StateLicense IDTaxonomies
CAC388522208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC388522Medicare UPIN