Provider Demographics
NPI:1497711063
Name:MONSOUR, FREDERICK J (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:J
Last Name:MONSOUR
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 1:6 FERNWOOD TRL
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-4955
Mailing Address - Country:US
Mailing Address - Phone:386-677-8561
Mailing Address - Fax:386-677-8561
Practice Address - Street 1:201 BILL FRANCE BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-1316
Practice Address - Country:US
Practice Address - Phone:386-254-6800
Practice Address - Fax:386-254-6995
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-24
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00422032085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL044772200Medicaid
FL044772200Medicaid
FLD70682Medicare UPIN