Provider Demographics
NPI:1275561656
Name:MANSOUR, MOURAD LABIB (MD)
Entity Type:Individual
Prefix:
First Name:MOURAD
Middle Name:LABIB
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 1:3001 W ILLINOIS AVE
Mailing Address - Street 2:STE: 8A
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79701-3180
Mailing Address - Country:US
Mailing Address - Phone:432-683-4773
Mailing Address - Fax:432-683-4773
Practice Address - Street 1:3001 W ILLINOIS AVE
Practice Address - Street 2:STE: 8A
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701-3180
Practice Address - Country:US
Practice Address - Phone:432-683-4773
Practice Address - Fax:432-683-4773
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1134207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1120818-01Medicaid
751764435797010000OtherTRICARE
00MA81Medicare ID - Type Unspecified
C18760Medicare UPIN