Provider Demographics
NPI:1417934522
Name:MANSOUR, MARC P (MD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:P
Last Name:MANSOUR
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:541 MAIN ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SOUTH WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02190-1868
Mailing Address - Country:US
Mailing Address - Phone:781-952-1280
Mailing Address - Fax:781-952-1570
Practice Address - Street 1:541 MAIN ST
Practice Address - Street 2:SUITE 210
Practice Address - City:SOUTH WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-1868
Practice Address - Country:US
Practice Address - Phone:781-952-1280
Practice Address - Fax:781-952-1570
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2014-03-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA74727207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ13523OtherBLUE CROSS BLUE SHIELD
MA3107051Medicaid
MA61619OtherHARVARD PILGRIM
MA074727OtherTUFTS HEALTH PLAN
MA3107051Medicaid
MAJ13523Medicare PIN