Provider Demographics
NPI:1003848854
Name:MANSOUR, MOHAMED
Entity Type:Individual
Prefix:
First Name:MOHAMED
Middle Name:
Last Name:MANSOUR
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 1:2912 210TH PL
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11360-2433
Mailing Address - Country:US
Mailing Address - Phone:718-773-2011
Mailing Address - Fax:718-773-3728
Practice Address - Street 1:2912 210TH PL
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11360-2433
Practice Address - Country:US
Practice Address - Phone:718-773-2011
Practice Address - Fax:718-773-3728
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY191343207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY07J841Medicare PIN
NYF59133Medicare UPIN