Provider Demographics
NPI:1720110182
Name:MANOOCHEHR MAZLOOMDOOST P S C
Entity type:Organization
Organization Name:MANOOCHEHR MAZLOOMDOOST P S C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DANESH
Authorized Official - Middle Name:
Authorized Official - Last Name:MAZLOOMDOOST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-275-4878
Mailing Address - Street 1:101 N EAGLE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-1806
Mailing Address - Country:US
Mailing Address - Phone:859-275-4878
Mailing Address - Fax:859-276-5400
Practice Address - Street 1:1100 CUMBERLAND FALLS HWY
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-2715
Practice Address - Country:US
Practice Address - Phone:859-275-4878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X, 207LP2900X, 2084P2900X, 363A00000X
KY17083174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain MedicineGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty