Provider Demographics
NPI:1306549357
Name:MANSARAY, ISHMAIL SIDDRA
Entity type:Individual
Prefix:
First Name:ISHMAIL
Middle Name:SIDDRA
Last Name:MANSARAY
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 1:2807 WINTERBOURNE DR
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-9100
Mailing Address - Country:US
Mailing Address - Phone:240-606-3519
Mailing Address - Fax:
Practice Address - Street 1:2811 PENNSYLVANIA AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-3865
Practice Address - Country:US
Practice Address - Phone:202-894-6811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251S00000XAgenciesCommunity/Behavioral Health