Provider Demographics
NPI:1487002234
Name:JALALI ROUDSARI, MOHSEN (MD)
Entity type:Individual
Prefix:
First Name:MOHSEN
Middle Name:
Last Name:JALALI ROUDSARI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 REGENCY PLZ APT 200
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-3126
Mailing Address - Country:US
Mailing Address - Phone:617-851-3872
Mailing Address - Fax:
Practice Address - Street 1:49 HILLSIDE ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-5211
Practice Address - Country:US
Practice Address - Phone:508-235-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-01
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA2852602084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program