Provider Demographics
NPI:1356322184
Name:MANSOOR, JOHN VICTOR (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:VICTOR
Last Name:MANSOOR
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 1:816 GREENBRIER CIR
Mailing Address - Street 2:SUITE A
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-2642
Mailing Address - Country:US
Mailing Address - Phone:757-461-6997
Mailing Address - Fax:757-461-6906
Practice Address - Street 1:1033 CHAMPIONS WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-3777
Practice Address - Country:US
Practice Address - Phone:757-461-6997
Practice Address - Fax:757-461-6906
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101054589207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006091326Medicaid
660001452OtherRAILROAD MEDICARE
VA0585010001OtherDME
VA660000024Medicare PIN
VA006091326Medicaid