Provider Demographics
NPI:1215360508
Name:MANSOUR, IYAD SAMI (MD)
Entity Type:Individual
Prefix:
First Name:IYAD
Middle Name:SAMI
Last Name:MANSOUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 OLD EUREKA WAY
Mailing Address - Street 2:STE 1E
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-0228
Mailing Address - Country:US
Mailing Address - Phone:530-232-3000
Mailing Address - Fax:530-242-8545
Practice Address - Street 1:2701 OLD EUREKA WAY STE 1E
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001
Practice Address - Country:US
Practice Address - Phone:530-232-3000
Practice Address - Fax:530-242-8545
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-09
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA154593207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine