Provider Demographics
NPI:1356314280
Name:MANSOUR, ELIE (MD FCCP)
Entity Type:Individual
Prefix:DR
First Name:ELIE
Middle Name:
Last Name:MANSOUR
Suffix:
Gender:M
Credentials:MD FCCP
Other - Prefix:DR
Other - First Name:ELIE
Other - Middle Name:
Other - Last Name:MANSOUR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD FCCP
Mailing Address - Street 1:719 NORTH BEERS STREET
Mailing Address - Street 2:SUITES 2E AND 2F
Mailing Address - City:HOLMDEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07733
Mailing Address - Country:US
Mailing Address - Phone:732-264-1001
Mailing Address - Fax:732-264-4495
Practice Address - Street 1:719 NORTH BEERS STREET
Practice Address - Street 2:SUITES 2E AND 2F
Practice Address - City:HOLMDEL
Practice Address - State:NJ
Practice Address - Zip Code:07733
Practice Address - Country:US
Practice Address - Phone:732-264-1001
Practice Address - Fax:732-264-4495
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06557207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8235104Medicaid
NJ035465PTKMedicare ID - Type Unspecified
NJ8235104Medicaid