Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207N00000X | Dermatologist | P6025 | TX |
NPI | 1053604389 |
---|---|
Provider Name | Dr. Bobbak Mansouri |
First Address | Tyler, TX 75703-1013 |
Second Address | Conroe, TX 77304-2954 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/05/2011 |
Last Update Date | 18/01/2022 |