Provider Demographics
NPI:1497905046
Name:MUGHAL, MANSOOR S (MD)
Entity Type:Individual
Prefix:MR
First Name:MANSOOR
Middle Name:S
Last Name:MUGHAL
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 1:1137 ASHFIELD WAY
Mailing Address - Street 2:
Mailing Address - City:ST. JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259
Mailing Address - Country:US
Mailing Address - Phone:904-388-8446
Mailing Address - Fax:904-384-6261
Practice Address - Street 1:2 SHIRCLIFF WAY
Practice Address - Street 2:STE. 715
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204
Practice Address - Country:US
Practice Address - Phone:904-388-8446
Practice Address - Fax:904-384-6261
Is Sole Proprietor?:No
Enumeration Date:2008-09-19
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR-8496207W00000X
NJ25MA10324500207W00000X
390200000X
FLME145502207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106346900Medicaid