Provider Demographics
NPI:1063724359
Name:JAMSHID A MARVASTI, M.D. P.C.
Entity type:Organization
Organization Name:JAMSHID A MARVASTI, M.D. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMSHID
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARVASTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-643-1166
Mailing Address - Street 1:130 PORTER ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-5438
Mailing Address - Country:US
Mailing Address - Phone:860-643-1166
Mailing Address - Fax:
Practice Address - Street 1:71 HAYNES ST
Practice Address - Street 2:MMH
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4131
Practice Address - Country:US
Practice Address - Phone:860-643-1166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-02
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT195152084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTB83784Medicare UPIN