Basic Information
| Provider Information | |||||||||
| NPI: | 1477744068 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANSOURI | ||||||||
| FirstName: | AZAD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3495 PIEDMONT RD NE | ||||||||
| Address2: | NINE PIEDMONT CENTER | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303051717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4045045678 | ||||||||
| FaxNumber: | 4103397326 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 MOUNT ZION PKWY | ||||||||
| Address2: | KAISER PERMANENTE SOUTHWOOD MEDICAL CENTER | ||||||||
| City: | JONESBORO | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302362500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103374500 | ||||||||
| FaxNumber: | 4103397326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2007 | ||||||||
| LastUpdateDate: | 01/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 0101247198 | VA | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | D70402 | MD | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | 2006017512 | MO | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | 076153 | GA | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 1477744068 | 05 | VA | MEDICAID | 033505300 | 05 | MD | MEDICAID | 078242200 | 05 | DC | MEDICAID |