Provider Demographics
NPI:1396000923
Name:GEORGE MANSOUR MD, PA
Entity Type:Organization
Organization Name:GEORGE MANSOUR MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSOUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-366-7475
Mailing Address - Street 1:935 N BENEVA RD
Mailing Address - Street 2:SUITE 707
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34232-1397
Mailing Address - Country:US
Mailing Address - Phone:941-366-7475
Mailing Address - Fax:941-366-4920
Practice Address - Street 1:935 N BENEVA RD
Practice Address - Street 2:SUITE 707
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34232-1397
Practice Address - Country:US
Practice Address - Phone:941-366-7475
Practice Address - Fax:941-366-4920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-10
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0072190207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF79077Medicare UPIN