Provider Demographics
NPI:1144615220
Name:PATHAN, MANSUR (DO)
Entity Type:Individual
Prefix:
First Name:MANSUR
Middle Name:
Last Name:PATHAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46671 PINEHURST CIR
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48168-8488
Mailing Address - Country:US
Mailing Address - Phone:734-417-3078
Mailing Address - Fax:
Practice Address - Street 1:12701 TELEGRAPH RD STE 106
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-4087
Practice Address - Country:US
Practice Address - Phone:734-366-1361
Practice Address - Fax:734-366-1359
Is Sole Proprietor?:No
Enumeration Date:2015-04-05
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.014288207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology