Provider Demographics
NPI:1467459966
Name:ASSAR, MANSOUR H (MD)
Entity Type:Individual
Prefix:
First Name:MANSOUR
Middle Name:H
Last Name:ASSAR
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 1:3124 WILLOW CREEK RD STE 200
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-6610
Mailing Address - Country:US
Mailing Address - Phone:928-474-5286
Mailing Address - Fax:928-474-0171
Practice Address - Street 1:3124 WILLOW CREEK RD STE 200
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-6610
Practice Address - Country:US
Practice Address - Phone:928-474-5286
Practice Address - Fax:928-474-0171
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ23221207R00000X, 207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ317629Medicaid
27625Medicare ID - Type Unspecified
AZ317629Medicaid
F48747Medicare UPIN