Provider Demographics
NPI:1538423868
Name:MANSUBI, KAYWAN
Entity type:Individual
Prefix:
First Name:KAYWAN
Middle Name:
Last Name:MANSUBI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14005 WILDWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:SARATOGA
Mailing Address - State:CA
Mailing Address - Zip Code:95070-5830
Mailing Address - Country:US
Mailing Address - Phone:408-621-0869
Mailing Address - Fax:
Practice Address - Street 1:14005 WILDWOOD WAY
Practice Address - Street 2:
Practice Address - City:SARATOGA
Practice Address - State:CA
Practice Address - Zip Code:95070-5830
Practice Address - Country:US
Practice Address - Phone:408-621-0869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-02
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA66677183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist