Provider Demographics
NPI:1770555492
Name:MANOOCHEHR MAZLOOMDOOST PSC
Entity type:Organization
Organization Name:MANOOCHEHR MAZLOOMDOOST PSC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DANESH
Authorized Official - Middle Name:
Authorized Official - Last Name:MAZLOOMDOOST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-275-4878
Mailing Address - Street 1:101 N EAGLE CREEK DR # 120
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-1806
Mailing Address - Country:US
Mailing Address - Phone:859-275-4878
Mailing Address - Fax:859-276-5400
Practice Address - Street 1:101 N EAGLE CREEK DR # 120
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-1806
Practice Address - Country:US
Practice Address - Phone:859-275-4878
Practice Address - Fax:859-276-5400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-06
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain MedicineGroup - Single Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65941387Medicaid
KY5472Medicare PIN