Provider Demographics
NPI:1053319962
Name:MANSOUR, MERVAT B (MD)
Entity Type:Individual
Prefix:DR
First Name:MERVAT
Middle Name:B
Last Name:MANSOUR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 GATES AVE
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816
Mailing Address - Country:US
Mailing Address - Phone:718-377-2834
Mailing Address - Fax:
Practice Address - Street 1:2 AUER CT STE D
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-5824
Practice Address - Country:US
Practice Address - Phone:732-257-5530
Practice Address - Fax:732-257-5531
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY220228207RN0300X
NJ25MA08176800207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02139802Medicaid
NYH33853Medicare UPIN
NY639L71Medicare ID - Type Unspecified