Provider Demographics
NPI:1083826051
Name:MANSOIR, MARK FITZPATRICK (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:FITZPATRICK
Last Name:MANSOIR
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9312 EQUUS CIR
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33472-4308
Mailing Address - Country:US
Mailing Address - Phone:561-733-5877
Mailing Address - Fax:
Practice Address - Street 1:1873 LANTANA RD
Practice Address - Street 2:
Practice Address - City:LANTANA
Practice Address - State:FL
Practice Address - Zip Code:33462-2601
Practice Address - Country:US
Practice Address - Phone:561-533-5115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 003364152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist