Azad Mansouri, MD

Primary specialty

Ophthalmology PhysicianTaxonomy code 207W00000X

License

076153 Issued in GA

Practice address

2400 Mount Zion Pkwy
Kaiser Permanente Southwood Medical Center
Jonesboro, GA 30236-2500

Phone

(410) 337-4500

Fax

(410) 339-7326

NPI assigned

Aug 7, 2007

Last updated

Jan 10, 2022By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 4

Addresses

Other identifiers 3

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in GA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Specialty

Ophthalmology

Education

Washington University School of Medicine, 2006

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

The Southeast Permanente Medical GroupGroup PAC ID 6204829013, 823 clinicians

Practice addresses (Care Compare)

Procedures performed for Medicare patients

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: azad.mansouri.p1@direct.nri.nextgenshare.com

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• The Southeast Permanente Medical Group

  • Internal Medicine Physician
  • Atlanta, GA
  • NPI 1245266956
  Medicare reassignment Care Compare group NPD
• Frederick Health Hospital Inc

  dba Frederick Health Hospital

  • General Acute Care Hospital
  • Frederick, MD
  • NPI 1538165527
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1186444800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1641772800000",
    "number": "1477744068",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3495 PIEDMONT RD NE",
            "address_2": "NINE PIEDMONT CENTER",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "303051717",
            "telephone_number": "404-504-5678",
            "fax_number": "410-339-7326"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2400 MOUNT ZION PKWY",
            "address_2": "KAISER PERMANENTE SOUTHWOOD MEDICAL CENTER",
            "city": "JONESBORO",
            "state": "GA",
            "postal_code": "302362500",
            "telephone_number": "410-337-4500",
            "fax_number": "410-339-7326"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MANSOURI",
        "first_name": "AZAD",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-08-07",
        "last_updated": "2022-01-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207W00000X",
            "taxonomy_group": "",
            "desc": "Ophthalmology",
            "state": "VA",
            "license": "0101247198",
            "primary": false
        },
        {
            "code": "207W00000X",
            "taxonomy_group": "",
            "desc": "Ophthalmology",
            "state": "MD",
            "license": "D70402",
            "primary": false
        },
        {
            "code": "207W00000X",
            "taxonomy_group": "",
            "desc": "Ophthalmology",
            "state": "MO",
            "license": "2006017512",
            "primary": false
        },
        {
            "code": "207W00000X",
            "taxonomy_group": "",
            "desc": "Ophthalmology",
            "state": "GA",
            "license": "076153",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1477744068",
            "state": "VA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "078242200",
            "state": "DC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "033505300",
            "state": "MD"
        }
    ],
    "endpoints": [
        {
            "endpointType": "SOAP",
            "endpointTypeDescription": "SOAP URL",
            "endpoint": "https://careepiceast.kp.org:14430/Interconnect-prodgam/wcf/epic.community.hie/xcpdrespondinggatewaysync.svc/ceq",
            "affiliation": "Y",
            "endpointDescription": "Carequality",
            "affiliationName": "Permanente Medical Group",
            "use": "HIE",
            "useDescription": "Health Information Exchange (HIE)",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "C-CDA",
            "address_1": "2400 Mount Zion Pkwy",
            "city": "Jonesboro",
            "state": "GA",
            "country_code": "US",
            "postal_code": "302362500",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Celestine O Maiki, MD
• Jerome A Maislis, PA-C
• Charles F Major Jr., D.M.D.
• Sylvester B Malcom, D.D.S.
• Mercy B Manga, NP-C
• Michelle Maples, RN
• Roland K Mapp
• Eddra Y Marchand, MD
• Marietta Healthcare (Southern Healthcare)
• Heather Markovitch

• Ophthalmology Physician in Jonesboro, GA
• Providers in Jonesboro, GA by specialty
• Ophthalmology Physician in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 10, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.