Provider Demographics
NPI:1376506873
Name:MANSOUR, SAM EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:SAM
Middle Name:EDWARD
Last Name:MANSOUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:20 ROCK POINTE LN
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WARRENTON
Mailing Address - State:VA
Mailing Address - Zip Code:20186-2679
Mailing Address - Country:US
Mailing Address - Phone:703-443-0015
Mailing Address - Fax:703-738-7157
Practice Address - Street 1:20 ROCK POINTE LANE
Practice Address - Street 2:SUITE 201
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20186
Practice Address - Country:US
Practice Address - Phone:703-443-0015
Practice Address - Fax:703-738-7157
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2012-09-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0101233782207W00000X
MDD0059626207W00000X
DCMD 34095207W00000X
CAA49545207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010107067Medicaid
VA010107024Medicaid
DC037331500Medicaid
VA143213OtherBLUE CROSS BLUE SHIELD
VA00W140T01Medicare PIN
VA143213OtherBLUE CROSS BLUE SHIELD
VA010107067Medicaid